Cancer Patients and Mental Health – a Focus at ASCO 2017

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Woman doctor delivering bad news to black patient

A diagnosis of advanced cancer weighs heavily on patients and families, and causes significant emotional distress. While doctors focus on addressing the health of a patient, mental health and emotional needs are often left to only the cancer patient and their families. At this year’s American Society of Clinical Oncology (ASCO) meeting, the importance of improving mental health and reducing distress for patients was evident. A number of studies focused on improving patient Quality of Life (QoL) through intervention therapeutic approaches were presented.

One of these studies, called Conquer Fear, centered on the fear of recurrence for cancer survivors. Often times, cancer patients, especially those who are dealing with highly recurrent cancer types, are faced with the fear of recurrence long after they are treated. This type of fear causes anxiety that can affect a cancer survivor’s work, relationships, and mental health. According to the study’s authors, about 50% of all cancer survivors and 70% of young breast cancer survivors report moderate to high fear of recurrence. [1]

Face-to-face intervention
In this phase II randomized trial, survivors of stage I-III breast cancer, colorectal cancer, or melanoma were given a psychological intervention that focused on reducing this dilemma through 60-90 minute face-to-face sessions with a psycho-oncologist that lasted 10 weeks. These sessions focused on helping a the survivor accept the uncertainty of recurrence and be able to cope with this worry in a way that lets them focus on their goals and returning to their daily lives.

A total of 222 survivors participated were randomized in either the 10 week Conquer Fear intervention (n= 121), or were in a control group that received relaxation training (n= 101) consisting of 60 minute face-to-face sessions that focused on muscle relaxation, meditative relaxation, and visualization techniques.

Questionnaire
The outcomes of this study were measured using a 42-item questionnaire that determined total-fear-of-cancer-recurrence or FCRI, which is measured on a scale of 1-168, with higher numbers meaning higher fear level. These questionnaires were given immediately after intervention, and then given once again 3 and 6 months later.

A key finding in this study was that the average FCRI score at baseline was 82.7 in the intervention arm and 85.7 in the control arm. Interestingly, the primary outcome confirmed an average FCRI score reduction of 18.1 points in the intervention group, while those in the control group had an average reduction was 7.6 points. The authors noted that this represents a standardized effect size of 0.44, within the range and is considered clinically important.

Photo 1.0:  The 53rd American Society of Clinical Oncology (ASCO) Annual Meeting were over 40,000 physicians, researchers, and healthcare professionals from over 100 countries meeting at McCormick Place in Chicago, Ill. receive the learn about  latest findings in all major areas of oncology, from basic to clinical and epidemiological studies.

The FCRI scores continued to decrease over time, with a more dramatic decrease being seen in the Conquer Fear intervention group over time (6 months, decreasing by 27.2 points on average in the intervention group and 17.8 points on average in the control group).

And while these findings show that Conquer Fear is an effective strategy for dealing with fear of recurrence, authors did note that other, more easily accessible methods of relaxation and intervention could be effective, but psycho-oncologists are certainly useful for those with severe recurrence fears.

Resource-intensive
The authors agree that the Conquer Fear program is a time- and resource-intensive intervention. They conclude that other approaches, including programs via internet, in a group setting, or by phone, may be possible.  Another approach my include a stepped care approach in with only patients with severe fear of recurrence receiving face-to-face intervention.

“In this study, the interventions were delivered by experienced psycho-oncologists. It is possible that community psychologists or other professionals who have basic training in cognitive therapy could deliver the interventions, given appropriate training and supervision,” noted the lead study author Jane Beith, MD, PhD,  a Medical Oncologist at the University of Sydney in Australia, who developed the Conquer Fear intervention with colleagues.

CALM
Another study dealing with oncology and mental health took 305 patients with advanced stage cancer and subjected them to a psychological intervention that would assist them in dealing with their current positive cancer diagnosis. This intervention, called CALM (Managing Cancer And Living Meaningfully), focused on assisting patients in many aspects, including symptom control and medication decision making, changes in personal relationships and self-care, spiritual well-being, and future oriented concerns and mortality. [2]

This randomized clinical study, which included 305 patients with advanced cancer, found that when compared to the patients in an usual care control group, the CALM intervention patients reported less severe depressive symptoms at three months (52% CALM vs. 33% usual care) – a difference that grew even more so at six months (64% CALM vs. 35% usual care).

The CALM group reported greater preparation for their end of life, more willingness to talk about concerns for their future, and greater reduction in fear and an increased ability to deal with emotions. Importantly, clinically important reduction in severity of symptoms was seen in those patients with severe, clinically significant depression. There are now hopes to have physicians better understand the process of CALM and how it may benefit the quality of a patient’s life.

“This brief talking therapy [called CALM] helps patients facing advanced cancer, and their loved ones, sustain what is meaningful in their life despite its limitations, and face the future,” noted lead study author Gary Rodin, MD, Head of the Department of Supportive Care at the Princess Margaret Cancer Centre in Toronto, Canada.

“[The Therapy] provides time and space for reflection on the threats and challenges associated with advanced cancer, the experience of a secure base in the therapeutic relationship, and support for the regulation and modulation of emotions,” Rodin added.

While face-to-face therapy and intervention methods may be very effective, another study presented at ASCO focused on program that can be become more accessible to both patient and doctor by being administered via the web.

“The number of people surviving cancer is higher than ever before, but many survivors fear that the cancer will return even long after they have finished treatment. The hope is that the positive results of this fear-reducing intervention will pave the way for making it more widely available to patients,” noted Don S. Dizon, MD, FACP, an ASCO Expert not involved with the studies mentioned in this article.

STREAM
The STREAM intervention method focused on connecting patients with online psychologists, in order to deliver support in an easy and more flexible manner. STREAM was developed by oncologists and psychologists, and is designed to support patients by helping them manage stress, social interactions, and emotions, without having the need to commit to face-to-face sessions that are typical of this type of therapy. [3]

Most of the 129 patients in this study were early-stage breast cancer patients, but also included were some patients with lung, ovarian, gastrointestinal cancer, and lymphoma and melanoma. Various measurement scales, such as Quality of Life (FACIT-F), distress (DT), and anxiety/depression (HADS) were utilized to record patient progress in the STREAM and control group. The DT scale measures distress on a scale of 1-10, with 0-4 scores being considered low distress, and those above 5 being considered high distress.

The study also pre-defined that a 9 point difference in FACIT-F score would be considered clinically significant.

After two months of the control and STEAM intervention, the patients in the STEAM group nearly reached a 8.59 point improvement in FACIT-F score when compared to the control. The distress score also was reduced by 2 points total, falling from a 6 in the control group to a 4 in the STEAM intervention group. As for depression or anxiety, there was no measurable difference found between either group. While still in early stages of research, assessable, online programs like STEAM are showing promise for managing quality of life in cancer patients.


Last editorial review: June 4, 2017

Featured Image: Delivering bad news to a patient Courtesy: © 2017 Fotolia. Used with permission. Photo 1.0: Attendees of ASCO. Courtesy: © ASCO/Scott Morgan. Used with permission.

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