A Systematic Review of Interventions for Health Anxiety Presentations Across Diverse Chronic Illnesses.

PURPOSE: Health anxiety (HA) is associated with reduced quality of life among individuals with chronic illnesses. However, little is known about effective interventions for reducing HA in this context. This study aimed to comprehensively review the literature on interventions for the treatment of HA in chronic illness. METHODS: This study was conducted as part of a larger systematic review on HA among individuals diagnosed with a chronic illness, using literature published between January 1996 and October 2017. A total of 51 articles were selected as they reported on interventions with pre-post measures and described the impact of the intervention on HA. RESULTS: The data on psychotherapy (CBT, third-wave CBT, and mindfulness), patient education, and rehabilitation programs demonstrated effectiveness in cancer and cardiac patients. Exercise interventions demonstrated effectiveness in patients with Parkinson's disease, and medical interventions showed limited effectiveness in reducing HA in diabetes and epilepsy. Most interventions yielding significant outcomes were at least 6 to 8 weeks long. CONCLUSIONS: The literature supports that a variety of interventions may be effective in reducing HA in individuals with chronic illness. Future research should test single interventions across several illnesses, as well as several interventions within a single illness to better understand how HA can be managed across chronic illnesses.

Towards the validation of a new, blended theoretical model of fear of cancer recurrence.

OBJECTIVE: Fear of cancer recurrence (FCR) is defined as "fear, worry, or concern about cancer returning or progressing". To date, only the seminal model proposed by Lee-Jones and colleagues has been partially validated, so additional model testing is critical to inform intervention efforts. The purpose of this study is to examine the validity of a blended model of FCR that integrates Leventhal's Common Sense Model, Mishel's Uncertainty in Illness Theory, and cognitive theories of worry. METHODS: Participants (n = 106) were women diagnosed with stage I to III breast or gynecological cancer who were enrolled in a Randomized Controlled Trial of a group cognitive-existential intervention for FCR. We report data from standardized questionnaires (Fear of Cancer Recurrence Inventory-Severity and Triggers subscales; Illness Uncertainty Scale; perceived risk of recurrence; Intolerance of Uncertainty Scale; Why do people Worry about Health questionnaire; Reassurance-seeking Behaviors subscale of the Health Anxiety Questionnaire, and the Reassurance Questionnaire) that participants completed before randomization. Path analyses were used to test the model. RESULTS: Following the addition of four paths, the model showed an excellent fit (χ2 = 13.39, P = 0.20; comparative fit index = 0.99; root mean square error of approximation = 0.06). Triggers, perceived risk of recurrence, and illness uncertainty predicted FCR. FCR was associated with maladaptive coping. Positive beliefs about worrying and intolerance of uncertainty did not predict FCR but led to more maladaptive coping. CONCLUSIONS: These results provide support for a blended FCR model.

Examining the preliminary efficacy of an intervention for fear of cancer recurrence in female cancer survivors: a randomized controlled clinical trial pilot study.

PURPOSE: Among cancer survivors, fear of cancer recurrence (FCR) is the most frequently reported unmet need. Despite this, research on psychosocial interventions that target FCR is limited. To address this gap, an individual cognitive-existential psychotherapy intervention for FCR was pilot tested via small-scale RCT. METHODS: Participants were recruited via study posters, healthcare professionals' referrals, and an electronic hospital database. Twenty-five female cancer survivors were randomized to experimental or wait-list control groups. Sessions included cognitive restructuring techniques, behavioral experiments, discussion of existential concerns, and relaxation exercises. Nineteen women completed the 6-week intervention and completed questionnaire packages at various time points. All participants completed self-administered questionnaires at pre-intervention (T1), post-intervention (T2), and at 3-month follow-up (T3). Participants in the control group also completed the same questionnaires, including at baseline (T0). RESULTS: Statistically significant results of between-within ANOVAs included time by condition interactions in the primary outcome measure of FCR and, for the experimental group participants, time by condition interactions in the secondary outcome measures of cancer-specific distress and uncertainty in illness. Statistically significant results of repeated measures ANOVAs included reductions in FCR, cancer-specific distress, uncertainty in illness, reassurance seeking, cognitive avoidance, and intolerance of uncertainty, as well as improvements in positive reinterpretation and growth, emotional coping, and quality of life (improved mental health), when compared to the control group. Most changes were maintained at 3-month follow-up. CONCLUSIONS: This intervention responds to a need for evidence-based individual modality interventions targeting quality of life in cancer survivors. Our results demonstrate preliminary promising results in addressing FCR in female cancer survivors. Future research could seek to replicate results with a larger sample. Further research is needed to test this intervention with patients of mixed cancer sites.

An exploratory study of the worst-case scenario exercise as an exposure treatment for fear of cancer recurrence.

PURPOSE: The worst-case scenario (WCS) exercise is part of a manualized cognitive-existential group intervention for fear of cancer recurrence (FCR). It requires cancer survivors to describe the scenario they most fear when they think about the possibility of their cancer returning and to re-read the scenario daily for 1 week as homework. The purpose of this study was to present this novel clinical treatment for FCR and to examine whether at-home repeated exposure to the WCS was related to pre- and post-therapy FCR levels. METHODS: Women with breast and gynaecological cancers who received care at The Ottawa Hospital Cancer Centre were recruited to participate in this follow-up study. Consenting participants provided copies of their WCS exercises. RESULTS: The WCS of ten female cancer survivors were collected to examine the homework portion of the exercise. Higher adherence to homework was significantly related to lower post-therapy FCR but not to pre-therapy scores. CONCLUSIONS: Baseline levels of FCR may not be a factor influencing inter-session homework adherence to the WCS, while exposure to the WCS resulting from adherence to the homework exercise may influence post-therapy FCR outcomes. These effects remain to be differentiated from the overall therapeutic effect of the 6-week cognitive-existential intervention for FCR, using a larger sample. This study presents preliminary evidence for an upcoming multi-centre trial in which the WCS exercise will be re-examined with larger sample sizes.

Addressing fear of recurrence: improving psychological care in cancer survivors.

PURPOSE: Fear of cancer recurrence (FCR) is defined as "the fear or worry that the cancer will return or progress in the same area or another part of the body." FCR is associated with impaired functioning and lower quality of life in cancer patients. A cognitive-existential (CE) manualized group intervention for women with FCR showed a moderate effect size in reducing FCR, cancer-specific distress, and maladaptive coping. However, it appears that no individual intervention for FCR exists for both men and women. Therefore, the group intervention was adapted to an individual format. METHODS: This study was conducted to determine the feasibility, acceptability, and satisfaction of the individual intervention. The intervention was pilot-tested on n = 3 cancer survivors. The 6-week sessions included cognitive restructuring, structured exercises, and relaxation techniques. Participants completed questionnaire packages during a 4-week baseline period and throughout the 6-week intervention. Participants completed exit interviews following the intervention. RESULTS: General trends in baseline and intervention stages were compared. Based on the line graphs, the individual intervention appears to help survivors lower their elevated FCR and cancer-specific distress. Qualitative exit interviews conducted with the study participants demonstrated that the intervention was acceptable and satisfactory. CONCLUSIONS: This clinical intervention allows researchers to systematically focus on evidence-based treatments for managing FCR, and displays the availability of treatment options in different therapeutic modalities. However, further research is needed to identify the active therapeutic ingredients and mechanisms of change in the intervention. Overall, intervention studies suggest it is possible to help cancer survivors manage their FCR.

When fear of cancer recurrence becomes a clinical issue: a qualitative analysis of features associated with clinical fear of cancer recurrence.

PURPOSE: Fear of cancer recurrence (FCR) is a common experience for cancer survivors. However, it remains unclear what characteristics differentiate non-clinical from clinical levels of FCR. The goal of this study was to investigate the potential hallmarks of clinical FCR. METHODS: A convenience sample of 40 participants (n = 19 female) was drawn from another study (Lebel et al. in Qual Life Res 25:311-321. doi: 10.1007/s11136-015-1088-2 , 2016). The semi-structured interview for fear of cancer recurrence (Simard and Savard in J Cancer Surviv 9:481-491. doi: 10.1007/s11764-015-0424-4 , 2015) was used to identify participants with non-clinical and clinical FCR and qualitative analysis of these interviews was performed. RESULTS: Individuals with clinical FCR reported the following features: death-related thoughts, feeling alone, belief that the cancer would return, experiencing intolerance of uncertainty, having cancer-related thoughts and imagery that were difficult to control, daily and recurrent, lasted 30 minutes or more, increased over time, caused distress and impacted their daily life. Triggers of FCR and coping strategies did not appear to be features of clinical FCR as they were reported by participants with a range of FCR scores. CONCLUSIONS: While features of clinical FCR found in this analysis such as intrusive thoughts, distress and impact on functioning confirmed previous FCR research, other features spontaneously emerged from the interviews including "death-related thoughts," "feeling alone," and "belief that the cancer will return." The participants' descriptions of cancer-specific fear and worry suggest that FCR is a distinct phenomenon related to cancer survivorship, despite similarities with psychological disorders (e.g., Anxiety Disorders). Future research investigating the construct of FCR, and the distinguishing features of clinical FCR across a range of cancer types and gender is required.

Does fear of cancer recurrence predict cancer survivors' health care use?

INTRODUCTION: Fear of cancer recurrence (FCR) is the most frequently cited unmet need among cancer survivors. Theoretical models of FCR suggest that patients with elevated levels of FCR will more frequently consult health care professionals for reassurance about their health. However, the relationship between FCR and health care utilization has not yet been firmly established. We examined the relationship between FCR and quantity of medications, number of emergency room (ER) visits, outpatient visits, specialist visits, allied health visits, and hospital overnight visits. METHODS: A total of 231 participants diagnosed with breast, colon, prostate, or lung cancer in the past 10 years were recruited from a cancer survivor registry. Participants were sent a survey package that included demographic and medical characteristics, a health care utilization questionnaire, and the Fear of Cancer Recurrence Inventory. RESULTS: A multiple regression analysis indicated that higher FCR significantly predicted greater number of outpatient visits in the past 6 months (ß = .016, F(1, 193) = 5.08, p = .025). A hierarchical multiple regression indicated that higher FCR significantly predicted greater number of ER visits in the past 6 months when controlling for relationship status and education level (F(1, 179) = 4.00, p = .047). CONCLUSIONS: The relationship between FCR and health care use has been understudied. Results indicate that patients with elevated FCR may indeed use more health care services. We recommend that clinicians monitor health care use in patients who are struggling with FCR.

Fear of cancer recurrence therapy (FORT): A randomized controlled trial.

OBJECTIVE: Most fear of cancer recurrence (FCR) interventions have small effects, and few target FCR. This randomized controlled trial (RCT) with breast and gynecological cancer survivors evaluated the efficacy of a cognitive-existential fear of recurrence therapy (FORT) compared to an attention placebo control group (living well with cancer [LWWC]) on FCR. METHOD: One hundred and sixty-four women with clinical levels of FCR and cancer distress were randomly assigned to 6-weekly, 120 min FORT (n = 80) or LWWC (n = 84) group sessions. They completed questionnaires at baseline (T1), posttreatment (T2; primary endpoint), 3 (T3), and 6 months (T4) posttreatment. Generalized linear models were used to compare group differences in the fear of cancer recurrence inventory (FCRI) total score and secondary outcomes. RESULTS: FORT participants experienced greater reductions from T1 to T2 on FCRI total with a between-group difference of -9.48 points (p = .0393), resulting in a medium effect of -0.530, with a maintained effect at T3 (p = .0330) but not at T4. For the secondary outcomes, improvements were in favor of FORT, including FCRI triggers (p = .0208), FCRI coping (p = .0351), cognitive avoidance (p = .0155), need for reassurance from physicians (p = .0117), and quality of life (mental health; p = .0147). CONCLUSIONS: This RCT demonstrated that FORT, compared to an attention placebo control group, resulted in a greater reduction in FCR posttreatment and at 3 months posttreatment in women with breast and gynecological cancer, indicating its potential as a new treatment strategy. We recommend a booster session to sustain gains. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Health anxiety and illness-related fears across diverse chronic illnesses: A systematic review on conceptualization, measurement, prevalence, course, and correlates.

BACKGROUND: Patients with chronic diseases commonly report fears of illness or symptoms recurring or worsening. These fears have been addressed from an illness-specific perspective (e.g., fear of cancer recurrence), a generic illness perspective (e.g., fear of progression), and a psychiatric perspective (DSM-5 illness anxiety disorder and somatic symptom disorder). The broader concept of health anxiety (HA) can also be applied to patients with a chronic disease. This review was conducted to investigate the conceptual, theoretical, measurement-overlap, and differences between these distinct perspectives. We also aimed to summarize prevalence, course, and correlates of these fears in different chronic illnesses. METHODS: We used PsycINFO, PubMED, CINAHL, Web of Science, SCOPUS, and PSYNDEX to conduct a systematic review of studies pertaining to these fears in chronic illness published from January 1996 to October 2017. A total of 401 articles were retained. RESULTS: There were commonalities across different conceptualizations and diseases: a high prevalence of clinical levels of fears (>20%), a stable course over time, and a deleterious impact on quality of life. Reviewed studies used definitions, models, and measures that were illness-specific, with only a minority employing a psychiatric perspective, limiting cross-disease generalizability. There appears to be some applicability of DSM-5 disorders to the experience of fear of illness/symptoms in patients with a chronic illness. While conceptualizing HA on a continuum ranging from mild and transient to severe may be appropriate, there is a lack of agreement about when the level of fear becomes 'excessive.' The definitions, models, and measures of HA across chronic illnesses involve affective, cognitive, behavioral, and perceptual features. CONCLUSIONS: The concept of HA may offer a unifying conceptual perspective on the fears of illness/symptoms worsening or returning commonly experienced by those with chronic disease.

Breast and ovarian cancer survivors' experience of participating in a cognitive-existential group intervention addressing fear of cancer recurrence.

PURPOSE: Currently, very few clinical approaches are offered to cancer survivors dealing with fear of cancer recurrence (FCR). This paper provides an overview of cancer survivors' experience and satisfaction after taking part in a six-week, cognitive-existential (CE) group intervention that aimed to address FCR. METHOD: In this qualitative descriptive study, 12 women with breast or ovarian cancer provided in-depth interviews of their experience in taking part in the CE group intervention. RESULTS: Analysis of their accounts revealed struggles to face their fears. Yet, by embracing their group experience, the women learned how to confront their fears and gain emotional control. The women reported that the group work was highly valuable. CONCLUSION: From the women's analysed accounts, the authors have proposed recommendations for changes to the group work process before moving the study to a full clinical trial. The study's findings also provide valuable insights to other cancer survivor groups who may also be experiencing FCR.