Evaluation of a stepped-care approach (Fear-Less) to treat fear of cancer recurrence in cancer survivors

This study evaluates the feasibility and acceptability of a stepped-care model to identify and treat fear of cancer recurrence (FCR) in cancer survivors. This includes evaluating screening processes as well as the interventions offered. The stepped-care model involves stratified care, in which participants will be stratified to the steps below based on their scores on the Fear of Cancer Recurrence Inventory – Short Form (FCRI-SF). Step 1: Treatment as usual Participants identified as experiencing low FCR (score of <13 on the FCRI-SF) will continue with their usual care with their medical and nursing teams, and will be provided details about how to access psychological intervention should they need services. No further follow-up or additional screening will be undertaken for these participants. These participants will be asked to complete an evaluation survey about their screening experiences. Step 2: Guided self-management intervention (duration = 5 weeks) Participants identified as experiencing moderate/subthreshold levels of FCR (score of 13-21 on FCRI-SF) will have a brief discussion with a clinical psychologist on the research team to confirm they are concerned about their level of FCR and would like support for it. Participants who agree to proceed will be offered the clinician-guided self-management intervention. The self-management resource is a colour printed booklet consisting of psychoeducation regarding FCR and strategies to manage FCR. The booklet was purposely designed for this study, based on an existing booklet developed by our team at Peter Mac for Stage 4 melanoma survivors experiencing FCR. A clinical psychologist will introduce and provide education regarding the resource at point of referral acceptance by the participant. This will occur by phone. The clinical psychologist will then provide the resource as a digital copy via email or hard copy by post (depending on participant preference). Participants will be contacted over the phone after approximately three weeks of receipt of the resource to provide phone support and further education as needed. Participants will also be contacted via phone five weeks after receipt of the self-management resource. During this call, final education and phone support will be offered. The participant may also re-complete the FCR screening measures over the phone, after which their current treatment needs and options for follow-up clinical support will be discussed. This may include no further treatment, or referrals to services such as a psychiatrist, individual therapy, peer supports or community services GP. Each phone call is expected to take 20 minutes. Participants will also be asked to complete an evaluation survey following the 5 week intervention to provide feedback and self-report their adherence to reading the resource and practising the strategies suggested. Step 3: Individual intervention (duration = 5 sessions) Participants identified as experiencing high/clinical levels of FCR (score of =>22 on the FCRI-SF) will have a brief discussion with a clinical psychologist on the research team member to confirm the severity of FCR and whether they would like support for it. Factors that will be assessed during this discussion will include the frequency, emotional impact, functional impact, and avoidance of FCR. Participants whose assessment indicates clinical levels of FCR will be offered ConquerFear. Participants who are considered to have sub-threshold FCR, or who do not wish to take part in the ConquerFear therapy, will be offered the self-management intervention. ConquerFear is an established treatment protocol for FCR, which consists of five individual sessions teaching survivors strategies to manage worry and excessive FCR, and promote value-based goal setting. Each session will be approximately 60 minutes every 1-2 weeks and will be facilitated by a clinical psychologist face-to-face or via telehealth as needed (e.g., general health recommendations during the pandemic). Face-to-face sessions will be held at Peter MacCallum Cancer Centre. Telehealth will be offered via online video sessions. Each session is accompanied by home-based practice of skills learned in session and home reading to consolidate skill acquisition. For example, participants are asked to practice the Attention Training Technique (15min) daily, or provided written material to consolidate what has been discussed during the session. It is expected this practice and reading will take 1-2 hours total between sessions. The key goals of the Conquer Fear therapy are to: a) Teach strategies for managing worry and excessive threat monitoring b) Modify underlying unhelpful beliefs about worry c) Develop appropriate monitoring and screening behaviours d) Educate about follow-up care and empirically-supported behavioural change (e.g., weight loss, exercise etc.) to reduce the risk of cancer recurrence e) Address existential changes brought about by a cancer diagnosis f) Promote goal-setting The fidelity of the ConquerFear treatment protocol will be assessed through a review of each session by the psychologists administering the treatment. This will be completed using session checklists usually included in the ConquerFear protocol. The checklist will be completed at the end of each session. At the final session, participants will be asked to re-complete FCR screening measures and their current treatment needs and options for follow-up clinical support will be discussed. This may include no further treatment, or referrals to services such as a psychiatrist, individual therapy, peer supports or community services GP. Participants will also be asked to complete an evaluation survey to provide feedback on the intervention.