A Web-Based Mindfulness-Based Cognitive Therapy for Couples Dealing With Chronic Cancer-Related Fatigue: Protocol for a Single-Arm Pilot Trial.

BACKGROUND: Chronic fatigue is a common symptom among patients who have been treated for cancer. Current psychosocial interventions typically target the patient alone, despite growing evidence suggesting that a couples' approach can increase and broaden the efficacy of an intervention. Therefore, based on an existing web-based mindfulness-based cognitive therapy for patients, the couple intervention COMPANION was developed. OBJECTIVE: The primary objectives of this study are to determine the acceptability of COMPANION and its potential efficacy in reducing fatigue in patients with cancer. Our secondary objectives are to examine the feasibility of the trial procedures and the potential working mechanisms of the couple intervention. METHODS: We will conduct a single-arm pilot trial for couples (ie, patients with cancer with chronic fatigue and their partners). All couples are allocated to the web-based couple intervention that consists of psychoeducation, mindfulness, and cognitive-behavioral exercises. The 9 sessions of the intervention are supervised remotely by a trained therapist. Patients and partners will complete questionnaires before starting the intervention (T0), 2 weeks after completing the intervention (T1), and 1 month after T1 (T2). They will also fill out weekly diaries during the intervention period. A subsample of patients (n≈5) and partners (n≈5) as well as all the therapists providing COMPANION will participate in the final focus groups. Benchmark values have been defined to determine the acceptability (ie, ≥60% of couples complete the intervention and/or ≥70% of the participants are satisfied with the intervention) and potential efficacy (ie, a significant improvement in fatigue and/or a clinically relevant improvement in fatigue in 45% of the patients between T0 and T1) of the intervention. The trial procedures are deemed feasible if an average of at least three couples are included per recruiting month and/or adherence to the assessments is at least 65% for T1 and the diaries and 60% for T2. To establish potential working mechanisms, changes in affect, sleep, catastrophizing, partner communication and interactions, self-efficacy, mindfulness, and closeness will be examined. Quantitative outcomes will be interpreted along with the results from the focus groups. RESULTS: Data collection is expected to be completed by March 2024. CONCLUSIONS: This pilot trial will test the first web-based mindfulness-based cognitive therapy for couples targeting chronic cancer-related fatigue. Findings will indicate whether proceeding with a randomized controlled trial is warranted. TRIAL REGISTRATION: ClinicalTrials.gov NCT05636696; https://clinicaltrials.gov/study/NCT05636696. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/48329.

Exploring the dynamic interconnectedness of protective and perpetuating factors of cancer-related fatigue.

OBJECTIVE: Approximately 25% of cancer patients suffer from cancer-related fatigue (CRF) after cancer treatment. CRF is a multi-factorial condition affected by several interrelated protective and perpetuating factors. As most studies merely assessed bivariate associations, more insight into the complex relationships among these constructs is needed. We applied the multivariate network approach to gain a better understanding of how patients' fatigue, perpetuating and protective factors are dynamically interconnected. METHOD: Between February and August 2022, 30 cancer patients filled out a carefully developed ecological momentary assessment questionnaire (EnergyInSight) five times a day for at least 21 days while being on the waitlist for psychological care for CRF. We performed a multi-level vector autoregression analysis to examine the interconnectedness among fatigue, protective factors (allowing rest, acceptance, and self-efficacy) and perpetuating factors (worrying, catastrophizing, and feeling guilty). RESULTS: In the contemporaneous network (concurrent associations), higher acceptance and self-efficacy were associated with lower fatigue, whereas all other factors were associated with higher fatigue. The strongest relationships were between worrying and feeling guilty and between acceptance and allowing rest. In the temporal network (lagged associations), fatigue was related to two factors: higher self-efficacy preceded lower fatigue, and higher fatigue preceded increased allowing rest. CONCLUSIONS: Taking all included factors into account, the networks identified self-efficacy and allowing rest as key protective factors of CRF. Patients may benefit from psychological interventions that cultivate self-efficacy, as it seems to pave the way to reduced fatigue.

CBT-based Online Self-help Training to Reduce Fear and Distress After Cancer (CAREST Randomized Trial): 24 Months Follow-up Using Latent Growth Models and Latent Class Analysis.

BACKGROUND: Psychological distress (PD) and fear of cancer recurrence (FCR) are common consequences of surviving cancer. Online self-help training could help many cancer survivors deal with PD and FCR at low costs. PURPOSE: To evaluate the long-term effectiveness of the CAncer REcurrence Self-help Training (CAREST trial) to reduce PD and FCR. Moreover, to evaluate the relation between FCR and PD across time and identify subgroups representing different change trajectories in FCR over time and their predictors. METHODS: This multicenter randomized controlled trial included 262 female breast cancer survivors, assigned to online self-help training or care as usual. Participants completed questionnaires at baseline and four times during the 24-month follow-up. The primary outcomes were PD and FCR (Fear of Cancer Recurrence Inventory). Latent growth curve modeling (LGCM) and repeated measures latent class analysis (RMLCA) were performed, both according to the intention-to-treat principle. RESULTS: LGCM showed no differences between the average latent slope in both groups for both PD and FCR. The correlation between FCR and PD at baseline was moderate for the intervention group and strong for the CAU group and did not significantly decrease over time in both groups. RMLCA revealed five latent classes and several predictors of class membership. CONCLUSIONS: We did not find a long-term effect of the CBT-based online self-help training in reducing PD or FCR, nor in their relation. Therefore, we recommend adding professional support to online interventions for FCR. Information about FCR classes and predictors may contribute to improvement of FCR interventions.

Many people experience distress and fear of recurrence after surviving cancer. Online psychological interventions have benefits, such as easy accessibility, flexibility, and low costs. But do they really help? In this study, we evaluated whether an online self-help training could reduce distress and fear of recurrence in breast cancer survivors. We compared two groups of patients; one received online self-help training and the other did not. Our first finding is that cancer survivors stay distressed and fearful for a long time (24 months in our study). A second finding is that we found five groups of patients with distinct levels of fear of recurrence and predictors for this fear. For instance, one group consisted of younger women with severe fear and more mental problems. Another group consisted of older women with mild fear but more physical problems. The most important finding of this study is that we did not find an effect of our self-help training. The persistence of distress and fear, and the different groups of cancer survivors with their specific characteristics and needs, underline the importance of developing effective psychological interventions. Given the benefits of online interventions, we recommend future studies concerning online interventions that provide professional support.

Navigating severe chronic cancer-related fatigue: an interpretative phenomenological analysis.

OBJECTIVE: This article presents a phenomenological study on the embodied experiences of patients with Chronic Cancer-Related Fatigue (CCRF), aiming to better understand this complex phenomenon. DESIGN: Data collection consisted of individual interviews with 25 participants who suffered from severe CCRF for at least three months after cancer treatment was finished. MAIN OUTCOME MEASURES: Against the theoretical background of philosophical phenomenology, we explored embodied experiences, incorporated temporal and spatial aspects of living with CCRF. We applied interpretative phenomenological analysis (IPA) to analyze the transcripts of the interviews. RESULTS: Using IPA, we identified four themes on how chronic fatigue is experienced post-cancer: (1) Worn out; (2) Diminishment of one's 'I can'; (3) Invisibility; and (4) Regaining one's 'I can'. CONCLUSION: For clinical practice, these results imply that professionals could focus more on the role of the body and limitations of one's 'I can' when treating CCRF. By studying these embodied CCRF experiences in individual patients, future research could help personalize and optimize treatment.

Using smartphone-based ecological momentary assessment and personalized feedback for patients with chronic cancer-related fatigue: A proof-of-concept study.

Introduction: Chronic cancer-related fatigue (CCRF) is a complex multidimensional problem warranting person-centered care. Providing patients and therapists personalized feedback based on network analysis applied to ecological momentary assessment (EMA) data could facilitate case conceptualization in psycho-oncological care. The aim was to explore patients' and therapists' experiences of using an EMA app and personalized feedback based on network theory to aid case conceptualization in psycho-oncological care. Methods: A n = 5 proof-of-concept study was implemented in routine psycho-oncological care. We purposively selected adult cancer patients suffering from severe CCRF who were on the waitlist for psycho-oncological care. During a 3-week period participants filled out the EMA app Energy InSight (fatigue, mood, activity, responding, and context) five times a day. Participants received a descriptive and network feedback report, which they reflected upon during the first therapy sessions. Thematic analysis was used to analyze user experiences. Results: Patients experienced that filling out the Energy InSight app, as well as receiving descriptive and network-based personalized feedback provided them with insight into their CCRF. Although therapists experienced the discussion of network feedback as challenging, it facilitated the case conceptualization. Discussion: Using EMA during waitlist for psychological care seemed feasible. Patients experienced beneficial effects from filling out the EMA app and talking over the personalized feedback reports, which in turn aided case conceptualization and personalized care. Based on this evaluation, an improved version of the Energy InSight app and a therapist training for providing network feedback is developed for implementation in psycho-oncological care.

Personalizing Psychological Care for Chronic Cancer-Related Fatigue: A Case Study on Symptom Dynamics.

Approximately 25% of cancer patients suffer from chronic cancer-related fatigue (CCRF), which is a complex, multifactorial condition. While there are evidence-based interventions, it remains unclear what treatment works best for the individual patient. Psychological network models can offer a schematic representation of interrelations among fatigue and protective and perpetuating factors for the individual patient. We explored whether feedback based on these individual fatigue networks can help personalize psychological care for CCRF. A 34-year old woman with CCRF was referred to our mental healthcare institute for psycho-oncology. During the waitlist period, she filled out an experience sampling app for 101 days, including five daily assessments of fatigue, pain, mood, activity and fatigue coping. The interplay between items was visualized in network graphs at the moment-level and day-level, which were discussed with the patient. For example, acceptance of fatigue in the past three hours was associated with less hopelessness and less fatigue in the following moment. At the day-level, acceptance was also being associated with less fatigue, less hopelessness, a better mood, and more motivation to do things. The patient recognized these patterns and explained how unexpected waves of fatigue can make her feel hopeless. This started a dialogue on how cultivating acceptance could potentially help her handle the fatigue. The patient would discuss this with her therapist. Feedback based on individual fatigue networks can provide direct insight into how one copes with CCRF and subsequently offer directions for treatment. Further research is needed in order to implement this in clinical practice.

Forming new habits in the face of chronic cancer-related fatigue: An interpretative phenomenological study.

PURPOSE: The growing group of patients who suffer from chronic cancer-related fatigue (CCRF) after cancer have helpful and less helpful ways of responding to this long-lasting and disruptive problem. This qualitative study aimed to gain insight in essential elements of how patients respond to CCRF, with a focus on helpful responses to facilitate adaptation. METHODS: We conducted semi-structured interviews with a purposive sample of 25 participants who experienced severe CCRF for at least 3 months. Participants were recruited via media, patient associations, meetings, and health professionals until data saturation was attained. We used a topic guide with open-ended questions about lived experiences. Interpretative phenomenological analysis (IPA) was used for analysis of the transcripts. RESULTS: We identified five interrelated themes of how patients respond to CCRF: (1) discovering physical and emotional boundaries; (2) communicating support needs; (3) reorganizing and planning activities and rest; (4) letting go of one's habitual identity; and (5) recognizing and accepting CCRF. CONCLUSION: This study highlights the development of new habits and positive beliefs in the face of CCRF and the importance of (social) support in this process. This experiential knowledge on helpful responses can be used to inform patients and their significant others and improve self-efficacy. Health professionals could use these insights to improve recognition of CCRF and personalize treatment.

Therapist behaviours in a web-based mindfulness-based cognitive therapy (eMBCT) for chronic cancer-related fatigue - Analyses of e-mail correspondence.

Web-based mindfulness-based cognitive therapy (eMBCT) has been found effective in decreasing fatigue severity in patients suffering from Chronic Cancer-Related Fatigue (CCRF). In web-based therapy, guidance from a therapist positively affects treatment outcome. So far, less is known about what kind of therapist behaviours contribute to treatment outcome. The present study aimed at 1) identifying therapist behaviours during eMBCT and 2) exploring whether these behaviours were correlated to a decrease in fatigue severity among patients. Qualitative content analyses were performed on 537 feedback e-mails from five therapists sent to 31 patients within a secured portal. Through content analyses, nine therapist behaviours were identified: emphatic utterances, probing self-reflection, informing, psychoeducation, task prompting, paraphrasing, task reinforcement, providing group context and alliance bolstering. Among these behaviours task prompting (19%), paraphrasing (16%) and task reinforcement (15%) were the most common. Linear regression analyses showed a significant association between informing and task prompting on the one hand and a decrease in fatigue severity on the other. Multivariate analysis indicated that informing and task prompting jointly explain the decrease in fatigue. These findings underline the importance for therapists to provide patients with sufficient information and to encourage them to do the exercises.

No effect of CBT-based online self-help training to reduce fear of cancer recurrence: First results of the CAREST multicenter randomized controlled trial.

OBJECTIVE: Fear of cancer recurrence (FCR) is a common consequence of surviving cancer; therefore, easily accessible self-help training could help many cancer survivors deal with FCR at low costs. The CAncer REcurrence Self-help Training (CAREST) trial evaluates the effectiveness of an online-tailored self-help training on the basis of evidence-based cognitive behavioral therapy principles in breast cancer survivors. Also, possible predictors for benefitting from the online self-help training were examined. METHODS: This multicenter randomized controlled trial included 262 female breast cancer survivors, randomly assigned to either online self-help training (n = 130) or care as usual (CAU; n = 132). Participants completed questionnaires at baseline (T0), 3 months (T1; after intervention), and 9 months (T2). The primary outcome was FCR (Fear of Cancer Recurrence Inventory Severity subscale). Both effectiveness and predictors were analyzed with latent growth curve modeling (LGCM) according to the intention-to-treat principle. RESULTS: LGCM showed no differences between the average latent slope in both groups (χ21  = .23, P = .63), suggesting that the treatments did not differ in their change in FCR over time. Moreover, no differences were found in the effects of the predictors on the latent slope in both groups (χ21  = .12, P = .73), suggesting that no significant predictors were found for the effect of the intervention on FCR. CONCLUSION: There was no effect of the CBT-based online self-help training "Less fear after cancer" in the current study. Therefore, we recommend adding professional support to online interventions for FCR.

Experiencing and responding to chronic cancer-related fatigue: A meta-ethnography of qualitative research.

OBJECTIVE: One of the most prevalent and disrupting symptoms experienced by cancer patients is chronic cancer-related fatigue (CCRF). A better understanding of the chronic nature of CCRF can provide valuable insights for theory and practice. The purpose of this meta-ethnography was to derive an overarching interpretative narrative on patients' experiences and responses to CCRF. METHODS: We conducted a comprehensive systematic literature search in five databases (05-03-2018). In addition, papers from reference lists were retrieved. Two researchers independently screened the papers for eligibility and appraised quality (CASP-criteria). We followed the seven phases of meta-ethnography to extract, translate, and synthesise first-order constructs (ie, patients' views) and second-order constructs (ie, authors' views) from the selected studies into third-order constructs (ie, new interpretations). RESULTS: Of the 1178 collected articles, 16 articles were included. Through synthesis, a new figure of six interrelated third-order constructs was developed: (1) embodied experience entails the dominating presence of the body; (2) (mis)recognition includes lack of recognition of CCRF by patients, relatives, and health providers; (3) small horizon describes a resultant narrowed world; (4) role change encompasses adopting other life roles; (5) loss of self refers to the impact on one's identity; and (6) regaining one's footing describes the struggle against CCRF, adaptation to CCRF and finally acceptance of a "new normal with CCRF." CONCLUSION: A new embodiment figure of CCRF with social (eg, (mis)recognition), spatial (eg, small horizon) and temporal dimensions (eg, regaining one's footing) was developed. This figure can help professionals to recognise CCRF, inform patients, and personalise treatment.