Study protocol of ConquerFear-HK: a randomised controlled trial of a metacognition-based, manualised intervention for fear of cancer recurrence among Chinese cancer survivors.

INTRODUCTION: Fear of cancer recurrence (FCR) is a prevalent and frequently debilitating response to a cancer diagnosis, affecting a substantial proportion of cancer survivors. Approximately 30% of local Hong Kong Chinese cancer survivors in a recent survey reportedly experienced persistent high FCR over the first-year post-surgery. This was associated with lower levels of psychological well-being and quality of life. A manualised intervention (ConquerFear) developed primarily based on the Self-Regulatory Executive Function Model and the Rational Frame Theory, has been found to reduce FCR effectively among Caucasian cancer survivors. The intervention now has been adapted to a Chinese context; ConquerFear-HK. The primary aim of this study is to evaluate its efficacy vs a standard-survivorship-care control (BasicCancerCare) in FCR improvement in a randomised control trial (RCT). METHODS AND ANALYSIS: In this RCT, using the sealed envelope method, 174 eligible Chinese cancer survivors will be randomised to either the ConquerFear-HK or BasicCancerCare intervention. Both interventions include six sessions over 10 weeks, which will be delivered via face to face or online by trained therapists. The ConquerFear-HK intervention incorporates value classification, metacognitive therapy, attentional training, detached mindfulness and psychoeducation; BasicCancerCare includes relaxation training, dietary and physical activity consultations. Participants will be assessed at prior randomisation (baseline; T0), immediately postintervention (T1), 3 months (T2) and 6 months postintervention (T3) on the measures of FCR (Fear of Cancer Recurrence Inventory) as a primary outcome; metacognition (30-item Metacognitions Quesionnaire) and cognitive attentional syndrome (Cognitive-attentional Syndrome Questionnaire) as process outcomes; psychological distress (Hospital Anxiety and Depression Scale), cancer-related distress (Chinese Impact of Events Scale), quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire) and treatment satisfaction are secondary outcomes. ETHICS AND DISSEMINATION: Ethics approval has been obtained from HKU/HA HKW Institutional Review Board (ref: UW19-183). The patients/participants provide their written informed consent to participate in this study. The study results will be disseminated through international peer-review publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT04568226.

The role of metacognition and its indirect effect through cognitive attentional syndrome on fear of cancer recurrence trajectories: A longitudinal study.

OBJECTIVE: This longitudinal study mapped distinct trajectories of fear of cancer recurrence (FCR) over 12 months among patients with breast (BC) or colorectal (CRC) cancer, and examined if metacognition, indirectly via attentional bias, intrusive thoughts and avoidance (hallmarks of cognitive attentional syndrome; CAS) predicted FCR trajectory membership. METHODS: Two hundred and seventy BC (n = 163) or CRC (n = 107) patients were assessed at 8-weeks, 3-, 6-, and 12-months postsurgery on a measure of FCR (FCRI-SF). Metacognition (MCQ-30), Intrusive and Avoidant Thoughts (CIES-R) and attentional bias (dot-probe tasks) were assessed at baseline. Latent growth mixture modeling identified FCR trajectories. Fully-adjusted Multinomial Logistic Regression identified whether direct and indirect effects of metacognition through CAS determined FCR trajectory membership. RESULTS: Three distinct FCR trajectories were identified, namely, low-stable (62.4%), high-stable (29.2%), and recovery (8.3%). Negative beliefs about worry, cognitive confidence, and age predicted FCR trajectories (χ2 (6) = 38.31, P<.001). Compared with Low-stable group, Recovery FCR patients held greater Negative beliefs about worry (OR = 1.13, P = .035) and High-stable FCR patients reported poorer Cognitive confidence (OR = 1.12, P = .004). The effect of Negative beliefs about worry was partially mediated by avoidance (ß = .06, 95% CIs 0.03-0.12) and fully mediated by intrusive thoughts (ß = .14, 95% CIs 0.08-0.20). Attentional bias did not predict FCR trajectories. CONCLUSIONS: While most patients experienced low level of FCR, 3 in 10 persistently worried about cancer returning over the first 12-months postsurgery. Modifying metacognitive knowledge to interrupt maladaptive cognitive processing including intrusion and avoidance may be an effective therapeutic intervention for patients at risk of persistent FCR.

Fear of cancer recurrence among Chinese cancer survivors: Prevalence and associations with metacognition and neuroticism.

OBJECTIVE: Fear of cancer recurrence (FCR) represents a chronic burden for many cancer survivors. We determined FCR prevalence and potential correlates, specifically metacognitive styles and neuroticism among Chinese cancer survivors with breast or colorectal cancer. METHODS: This study included 285 Chinese patients with breast (N = 173) and colorectal (N = 112) cancers at 8-week postsurgery. Participants completed a set of baseline questionnaires evaluating FCR (Fear of Cancer Recurrence Inventory-Short Form [FCRI-SF]), metacognition (Metacognitions Questionnaire-30), and neuroticism (Eysenck Personality Questionnaire). Scores of 13 to 21 were indicative of subclinical FCR on the FCRI-SF. Scores greater than or equal to 22 indicated clinically significant levels of FCR. Fully adjusted multinomial logistic regressions identified correlates of subclinical and clinically significant FCR. RESULTS: Respectively, 26.0% (n = 74) and 11.2% (n = 32) achieved scores indicating subclinical and clinically significant FCR. Expressing significantly more positive (OR = 1.21, P = .003) and negative (OR = 1.19, P = .005) beliefs about worry was associated with a higher likelihood of reporting subclinical FCR. Both higher neuroticism (OR = 1.28, P = .003) and more negative beliefs about worry (OR = 1.19, P = 0.035) were associated with an increased likelihood of experiencing clinically significant FCR. CONCLUSIONS: Positive and negative metacognitions may play an important role in the development of subclinical FCR. In particular, negative metacognition and neuroticism may elevate FCR from subclinical to a clinical level. The findings give insight into the identification of cancer survivors with subclinical or clinical FCR and aid the development of interventions aimed at changing metacognitive beliefs in order to manage FCR.

Communicative characteristics of interactions between surgeons and Chinese women with breast cancer in oncology consultation: a conversation analysis.

BACKGROUND: While previous studies have analysed features of interaction in cancer consultations using observational coding frames, relatively little attention is being given to how actual interactions are sequentially organized and achieved by participants in the course of talk-in-interaction. Research into the interactional practices in consultations, which involves Chinese patients, is largely absent. OBJECTIVE: To provide insight into the talk-in-interaction in surgical-oncology consultations in the context of a Chinese medical setting. METHODS: Thirty-one consultations involving 31 patients with breast cancer and eight surgeons were videotaped. The recordings were transcribed verbatim and analysed using conversation analysis. RESULTS: The manner in which surgeons delivered the diagnostic results was fairly similar across all the consultations. Most surgeons gave the diagnosis in a very straightforward and abrupt manner at the outset of the consultation with no mitigation. While patients in our study conformed to the traditional information giving and receiving roles, how information was presented by surgeons shaped the subsequent sequential organization of surgeon-patient interaction and turn-taking patterns. More importantly, there was a tendency by the surgeons to move from issues of psychosocial nature to clinical matters regardless of the topics taken up in the specific encounter. CONCLUSIONS: This study demonstrated the potential of conversation analysis as a context-sensitive method that enabled researchers to gain a more thorough understanding of dynamics of interaction in cancer consultations, thereby informing training interventions for surgeons. Our findings underscore the importance of discursive practices in shaping and encouraging (or discouraging) patient participation in oncology consultation.

Psychometric assessment of the Chinese version of the decisional conflict scale in Chinese women making decision for breast cancer surgery.

OBJECTIVE: The decisional conflict scale (DCS) measures the perception of uncertainty in choosing options, factors contributing to decision conflict and effective decision making. This study examined the validity and reliability of the Chinese version of the DCS in Hong Kong Chinese women deciding breast cancer (BC) surgery. METHOD: A Chinese version of the 16-item DCS was administered to 471 women awaiting initial consultation for BC diagnosis. Confirmatory factor analysis (CFA) assessed the factor structure. Internal consistency, and convergent and discriminant validities of the factor structure were assessed. RESULTS: CFA revealed the original factor structure of the DCS showed poor fit to this sample. Exploratory factor analysis revealed an alternative three-factor structure, Informed and Values Clarity, Uncertainty and Effective Decision and Support, was optimal. Cronbach's alpha ranged from 0.51 to 0.87. Correlations between decision-making difficulties and satisfaction with medical consultation demonstrated acceptable convergent validity. Construct validity was supported by correlations between decision regret and psychological distress. Discriminant validity was supported by differentiation between delaying and non-delaying decision-makers. CONCLUSIONS: The three-factor DCS-14 is a valid and practical measure for assessing decisional conflict in deciding BC surgery. It shows good potential for use in assessing decision satisfaction for women diagnosed with BC.

Does the use of shared decision-making consultation behaviors increase treatment decision-making satisfaction among Chinese women facing decision for breast cancer surgery?

OBJECTIVE: To assess the extent to which breast surgical consultations used shared decision making (SDM), identify factors associated with use of SDM, and assess if using SDM increases decision-making satisfaction. METHODS: Two hundred and eighty-three video-recorded diagnostic-treatment decision consultations between breast surgeons and women with breast cancer were assessed using the Decision Analysis System for Oncology (DAS-O) coding system designed for assessing SDM behaviors. Women completed a questionnaire at pre-consultation, one-week post-consultation and one-month post-surgery. Patient outcomes included decision conflict, patient satisfaction with medical consultation, and decision regret. RESULTS: Overall, the level of SDM behaviors was low. The extent of SDM behavior within consultation was related to greater consultation duration (p<0.001), more than one treatment being offered (p<0.001), and fewer questions raised by patients/companions (p<0.05). While use of SDM consultation did not influence post-consultation decision conflict, it increased satisfaction with information given and explained, patients' feelings of trust and confidence in their surgeons, and reduced post-surgical decision regret. CONCLUSION: These breast surgical consultations mostly adopted informed treatment decision-making approaches. Using SDM improved patient consultation and decision satisfaction. PRACTICE IMPLICATIONS: The study findings highlight a need to reinforce the importance of SDM in consultations among breast surgeons.

Reducing treatment decision conflict difficulties in breast cancer surgery: a randomized controlled trial.

PURPOSE: Breast cancer (BC) decision aid (DA) randomized studies are limited to DA use in consultations among Western populations and for primary surgery. Their effectiveness beyond consultations, for reconstructive surgery and in other populations, has not been evaluated. We developed a DA administered after consultation for Chinese women deciding on BC surgery and, where relevant, immediate breast reconstruction, which was evaluated in this randomized controlled trial (RCT). PATIENTS AND METHODS: Overall, 276 women considering BC surgery for early-stage BC were randomly assigned to receive a DA (take-home booklet) or the standard information booklet (control condition) after the initial consultation, wherein surgeons disclosed the diagnosis and discussed treatment options with patients. Using block random assignment by week, 138 women were assigned to the DA arm and 138 to the control arm. Participants completed interview-based questionnaires 1 week after consultation and then 1, 4, and 10 months after surgery. Primary outcome measures were decisional conflict, decision-making difficulties, BC knowledge 1 week after consultation, and decision regret 1 month after surgery. Secondary outcome measures were treatment decision, decision regret 4 and 10 months after surgery, and postsurgical anxiety and depression. RESULTS: The DA group reported significantly lower decisional conflict scores 1 week after consultation (P = .016) compared with women in the control arm. Women receiving the DA had significantly lower decision regret scores 4 (P = .026) and 10 months (P = .014) after surgery and lower depression scores 10 months after surgery (P = .001). CONCLUSION: This RCT demonstrated DAs may benefit Chinese patients in Hong Kong by reducing decisional conflict and subsequent regret and enhance clinical services for this population.

Waiting to see the doctor: understanding appraisal and utilization components of consultation delay for new breast symptoms in Chinese women.

BACKGROUND: Delayed consultation for potential cancer symptoms influences treatment outcomes and remains problematic. Delay components (Appraisal versus Utilization) and respective associations are poorly understood. METHODS: Eligible participants were Cantonese-speaking Chinese women, ≥21 years old, with self-discovered breast symptoms, recruited in surgical clinics before their first consultation, and naïve to their diagnosis. Overall 425/433 (98%) women completed a questionnaire on psychosocial, demographic and medical factors, how and when women discovered their breast symptom(s), and their subsequent decision making; 135/425 women (32%) were later diagnosed with breast cancer. RESULTS: Twenty-two per cent of women delayed >3 months before consultation. Women with breast cancer (28%) more often had prolonged delay than women with benign disease (19%). Attributing symptom to a non-cancerous condition, low fear on symptom discovery, not disclosing symptoms to others, and no prior breast symptom history predicted prolonged (>60 days) Appraisal Delay. Low fear on symptom discovery, seldom thinking about the symptom, and consultation for other reasons predicted prolonged (>14 days) Utilization Delay. Factors predicting Appraisal and Utilization Delays differentiated cancer from non-cancer groups. CONCLUSIONS: Indecision over symptom meaning comprised the main component of Appraisal and Total Delay, suggesting that educational strategies targeting atypical symptoms should reduce avoidable delays following self-discovered breast symptoms.

Trajectories of body image and sexuality during the first year following diagnosis of breast cancer and their relationship to 6 years psychosocial outcomes.

We examined degree and determinants of change in body image and sexuality over the first year following breast cancer diagnosis to differentiate body image and sexuality trajectories, and then explored if differences in trajectories predicted 6 years' psychosocial outcomes. 363/405 (90%) Chinese women receiving surgery for BC were assessed at 5-days (Baseline), 1-month, 4-months, and 8-months post-surgery. Psychological distress, treatment decision making (TDM) difficulties, satisfaction with treatment outcome, optimism, and self-efficacy were assessed at Baseline. Self-image and sexuality were recorded at each follow-up assessment. Latent growth mixture modeling identified trajectories of self-image and sexuality. Multinominal logistic regression identified factors predicting trajectory patterns. Six years later 211/363 (58%) of the original patients were successfully traced and their psychosocial status assessed. Three distinct trajectories of self-image and sexuality were identified: high-stable, recovery, and high-deteriorating. Most women (64% self-image; 58% sexuality) showed stable levels of self-image and sexuality scores. TDM difficulties, satisfaction with treatment outcomes, physical symptom and psychological distress predicted trajectory patterns. Self-image trajectories over the first year diagnosis predicted 6-years psychosocial outcomes. Women with high-stable level of self-image had the best 6-year self-image and sexuality; women with initial low level of self-image had significantly greater long-term psychological distress. Low TDM difficulties and high treatment outcome satisfaction predicted high and stable self-image and sexuality. Type of surgery showed little impacts on self-image and sexuality. Self-image during acute illness phase predicted long-term outcomes. Interventions should focus on minimizing self-image decrement.

Development and pilot-testing of a Decision Aid for use among Chinese women facing breast cancer surgery.

BACKGROUND: Women choosing breast cancer surgery encounter treatment decision-making (TDM) difficulties, which can cause psychological distress. Decision Aids (DAs) may facilitate TDM, but there are no DAs designed for Chinese populations. We developed a DA for Chinese women newly diagnosed with breast cancer, for use during the initial surgical consultation. AIMS: Conduct a pilot study to assess the DA acceptability and utility among Chinese women diagnosed with breast cancer. METHODS: Women preferred the DA in booklet format. A booklet was developed and revised and evaluated in two consecutive pilot studies (P1 and P2). On concluding their initial diagnostic consultation, 95 and 38 Chinese women newly diagnosed with breast cancer received the draft and revised draft DA booklet, respectively. Four-day post-consultation, women had questionnaires read out to them and to which they responded assessing attitudes towards the DA and their understanding of treatment options. RESULTS: The original DA was read/partially read by 66/22% (n = 84) of women, whilst the revised version was read/partially read by 74/16% (n = 35), including subliterate women (χ(2) = 0.76, P = 0.679). Knowledge scores varied with the extent the booklet was read (P1: F = 12.68, d.f. 2, P < 0.001; P2: F = 3.744, d.f. 2, P = 0.034). The revised, shorter version was graphically rich and resulted in improved perceived utility, [except for the 'treatment options' (χ(2) = 5.50, P = 0.019) and 'TDM guidance' (χ(2) = 8.19, P = 0.004) sections] without increasing anxiety (F = 0.689, P = 0.408; F = 3.45, P = 0.073). CONCLUSION: The DA was perceived as acceptable and useful for most women. The DA effectiveness is currently being evaluated using a randomized controlled trial.

Trajectories of psychological distress among Chinese women diagnosed with breast cancer.

BACKGROUND: The distinct trajectories of psychological distress over the first year of the diagnosis with breast cancer (BC) and its determinants have not been explored. METHODS: 285 of 405 Chinese women receiving surgery for BC were assessed at 5-day, 1-month, 4-month, and 8-month post-surgery on measures of psychological distress, optimism, treatment decision-making (TDM) difficulties, satisfaction with treatment outcome, satisfaction with medical consultation, and physical symptom distress. Latent growth mixture modelling identified trajectories of psychological response to BC. Multinominal logistic regression compared TDM difficulties, satisfaction with treatment outcome, satisfaction with medical consultation, optimism, and physical symptom distress, by distress pattern adjusted for age, education, employment status, and stage of disease. RESULTS: Four distinct trajectories of distress were identified, namely, resilience (66%), chronic distress (15%), recovered (12%), and delayed-recovery (7%). TDM difficulties, optimism, satisfaction with consultation, and physical symptom distress predicted distress trajectories. Psychologically resilient women had less physical symptom distress at early post-surgery compared with women with other distress patterns. Compared with the resilient group, women in the recovered or chronic distress groups experienced greater TDM difficulties, whereas women in the delayed-recovery group reported greater dissatisfaction with the initial medical consultation. Women in the chronic distress group reported greater pessimistic outlook. CONCLUSION: Optimism and better early post-operative treatment outcomes predicted resilience to distress. Pre-operative interventions helping women to establish a realistic expectation of treatment outcome may minimize disappointment with treatment outcome and resultant distress, whereas post-operative rehabilitation should focus on symptom management.

Social adjustment among Chinese women following breast cancer surgery.

BACKGROUND: How breast cancer surgery affects social adjustment among Chinese women is unknown, as are factors predicting such adjustment. METHODS: 405 Chinese women receiving surgery for localized breast cancer completed Social Adjustment Scales (Ch-SAS) at 1-, 4- and 8-months post-operatively. Subscale scores were regressed on baseline (days 3-12 post-operatively) measures of treatment decision-making difficulty (TDMD), self-efficacy (GSeS), consultation satisfaction (C-MISS-R), psychological (CHQ-12) and physical distress (PD), and 1-month follow-up optimism (C-LOT-R), and disappointment (E-OI), fully adjusted for demographic and clinical factors. RESULTS: All Ch-SAS subscales except appearance & sexuality changed significantly over 8-months follow-up: Enjoyment of social activities (F=27.38, df 2, p<0.001) and self-image (F=3.63, df 2, p=0.027) improved slightly. Family interaction (F=26.63, df 2, p<0.001) and interaction with friends (F=3.37, df 2, p=0.035) declined slightly. Family and friends interaction subscales were predominantly predicted by high self-efficacy and optimism, whereas self-image and appearance & sexuality subscales were predominantly predicted by low treatment outcome disappointment, TDM difficulties, baseline psychological morbidity and high self-efficacy. Enjoyment of social activities was predicted by low baseline psychological distress and concurrent physical symptom distress. CONCLUSION: High self-efficacy and optimism predicted women who have better social relationships with friends and family. Higher self-efficacy, low TDM difficulties, less disappointment with treatment outcome and low psychological and physical distress predicted better adjustment to self-image and body image.

Surgeon's recommendation, perceived operative efficacy and age dictate treatment choice by Chinese women facing breast cancer surgery.

PURPOSE: to identify factors influencing Chinese women's choices between breast-conserving therapy (BCT), mastectomy (MRM) or MRM followed by breast reconstruction (MRM+R). METHODS: of 405/443 Hong Kong Chinese women receiving surgery for early breast cancer who were interviewed one week post-surgery about their pre-surgical consultation, available treatment alternatives, whether their surgeons had indicated a surgical preference, perceived efficacy of the surgical options and considerations influencing their treatment decisions (TDM), 198 (49%) reported they were offered a choice of surgery. RESULTS: among women offered a choice of surgery, BCT was chosen by 34/43 (79%) of women whose surgeons recommended BCT but by only 34/96 (37%) of women whose surgeons expressed no treatment recommendation. Multivariate adjustment showed women choosing MRM were influenced more by avoiding both cancer recurrence (p = 0.003) and further treatment (p = 0.009) when choosing surgical option than women choosing BCT. In contrast, women choosing MRM+R and BCT, placed more emphasis on appearance (p < 0.001) and body image (p < 0.001) concerns as influencing treatment choice than did women who chose MRM. CONCLUSION: survival concerns rather than physical appearance, age and lack of recommendation push Chinese women to choose MRM as BCT is, incorrectly often seen as less efficacious. Recommending BCT increases BCT choice.

Gambling with your life: the process of breast cancer treatment decision making in Chinese women.

Treatment decision making (TDM) studies have primarily focused on assessing TDM quality and predominantly presume rational analytic processes as the gold standard. In a grounded theory study of 22 Hong Kong Chinese women following breast surgery who completed an in-depth interview exploring the process of TDM in breast cancer (BC), narrative data showed that discovery of a breast abnormality and emotional responses to BC diagnosis influence the TDM process. Lack of guidance from surgeons impaired TDM. Decisions were, for the most part, made using intuitive, pragmatic and emotionally driven criteria in the absence of complete information. The experience of TDM, which was likened to gambling, did not end once the decision was made but unfolded while waiting for surgery and the post-operative report. In this waiting period, women were emotionally overwhelmed by fear of death and the uncertainty of the surgical outcome, and equivocated over whether they had made the 'right' choice. This suggests that Chinese women feel they are gambling with their lives during TDM. These women are particularly emotionally vulnerable whilst waiting for their surgery and the post-surgical clinical pathology results. Providing emotional support is particularly important at this time when these women are overwhelmed by uncertainty.

Nipple-areola reconstruction in autologous breast reconstruction: Chinese patients' perspective.

Twenty-five consecutive patients who had nipple-areola reconstruction (NAR) using a modified S dermal-fat flap technique in the Division of Plastic Surgery, Department of Surgery, Kwong Wah Hospital, between 1995 and 2000 were studied. The nipple projection and sensation (to light touch and pinprick) were assessed by a designated surgeon who was not involved in the reconstructive process. This was followed by a questionnaire on the patients' perception of the various physical characteristics of the reconstructed nipple-areola complex (NAC) when in the nude. They were then asked to rate their satisfaction according to a 4-grade grading scale and whether they would recommend this procedure to other women with a similar condition. There was no major complication associated with this procedure. The mean projection of the reconstructed nipple at 18 months was 3.27 mm. The mean projection of the opposite normal nipple was 8 mm. The sensation to light touch and pinprick were 28% and 50% of the normal side, respectively. The majority of the patients were pleased with the reconstruction despite gradual loss of nipple projection and inadequate return of sensation. All patients would recommend this procedure to other women with similar disease. The creation of a NAC on the reconstructed breast mound seemed to enhance patients' satisfaction in this study.