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Fear of Recurrence for
Breast and Ovarian Cancer Survivors
A “Fear Management” (FM)Toolbox
Wendy G. Lichtenthal, PhD
Assis...
Why are you here today?
Because
This. Is. Hard.
Overview
• What we know about fear of recurrence
• Our group’s efforts to reduce fear of recurrence
• What you can do for ...
Fear of Cancer Recurrence:
Survivors’ Most Common Concern
• Rates range from 26% to as
high as 99%, depending on
measure u...
What do cancer survivors fear?
It varies from one person to another.
• Chemotherapy
• Surgery
• Radiation
• Hospitalizatio...
Higher levels of fear of recurrence
can be impairing
• Associated with depression and reduced
quality of life
• Associated...
And fear of recurrence is challenging to manage….
even for professionals.
• Beliefs are not irrational
• In a survey of 64...
Despite this, few psychosocial interventions have been
designed to specifically target fear of recurrence
Butow et al., 20...
In fact, management of fear of recurrence
is the number one unmet need of cancer survivors
American Cancer Society, 2007; ...
Thus, there has been a compelling need
to develop interventions that
directly target fear of cancer recurrence
JohnsonVick...
A PromisingTarget: Cognitive Biases
• Being attentive toward threat is often normative and adaptive
• Higher levels of anx...
Cognitive Bias Modification (CBM)
• Novel, brief, computerized intervention approach
• Rapid and repetitive computer tasks...
g (T2 v. Control) * p ** g (T3 v. Control) * p**
Experimental 0.35 .095 0.54 .005
* Hedges’ g effect sizes are standardize...
Conclusions from Study
• Both versions of AIM-FBCR appear to improve health
worries as compared to a placebo control condi...
So what can you do NOW
for Fear Management (FM)?
Trials examining interventions for fear of recurrence
• Conquer Fear (Butow et al., 2013): Ongoing RCT comparing 5-session...
Create your own FM toolbox
• Normalize and validate
• Share and process
• Make sense of your responses
• Establish effecti...
Normalize andValidate
• Give yourself permission to feel
• Use self-talk
• Check in with a friend, trusted family member, ...
Don’t underestimate
the power of sharing
Process your feelings and
make sense of your responses
• Understand the context: we all bring our own
– Personal cognitive...
Be compassionate toward the lens
through which you view the world
Establish effective ways to communicate
with your healthcare team
• What information do you need to know? (e.g., level of
...
Cognitive-Behavioral Strategies
van de Wal et al., 2015
My cancer is going to recur.
Scared
Avoidance,
checking,
reassuran...
Consider your beliefs about your anxiety
Self-Regulation of Executive Function (S-REF)
Butow et al.., 2013; Butow et al., ...
Cognitive responses:
Address distress with helpful thoughts
• Reframe thoughts related to both the benefits
and dangers of...
Change the meaning of the surges of anxiety
• Temporary
• Manageable
• Natural
Behavioral responses:
Address distress with helpful behaviors
• Minimize avoidance where possible (including allowing thou...
Mindfulness Strategies
• Moment-to-moment, non-judgmental
awareness:
NOTICING
• Pay attention to the present
moment (inclu...
Focus. Wander. Start over.
Leading with the mind:
Using focused attention
• Mindfulness meditation websites
– http://www.mindful.org/meditation/mindf...
Acceptance
• Maintain compassion toward
one’s thoughts
• Allow them to “be”…try not to
push them out
• Redirect your atten...
Walking the fine line between…
AcceptingYour Feelings
while
Redirecting Attention
Takes practice to work that “flexibility” muscle!
Leading with the body:
Use your body to discharge and
to bring you back to the here and now
• Progressive muscle relaxatio...
Find meaning in your life
• Write letters of gratitude to people in your life (Otto et al., 2016)
• Make go-to lists to re...
“Belief in a conditional world opens up the consideration of
multiple possibilities since certainty is not absolute."
Mish...
“Conditional” living can leave
you feeling stuck….
“Figure Stuck betweenTwoWalls”
byWilliamT. Ayton, 2009
So, how does one get “unstuck”?
Image courtesy of suphakit73 at FreeDigitalPhotos.net
First, validate rather than criticize your
feelings: this experience is HARD!
Then…
Consider the choice you have in how
you create meaning.
“…everything can be taken from a man but one
thing: the last of the human freedoms— to choose
one’s attitude in any given ...
RESPONSIBILITY
Breitbart & Applebaum, 2011; Breitbart & Poppito, 2010; Frankl, 1959/1984
The ability to respond to the
lif...
COURAGE
Breitbart & Applebaum, 2011; Breitbart & Poppito, 2010; Frankl, 1959/1984
Moving ahead in spite of uncertainty.
He who has a why to live for
can bear almost any how.
- Friedrich Nietzsche
Frankl, 1959/1984
What areYOUR whys?
Fear Management (FM):
Cultivating compassion toward yourself
• Understand your personal context and lens
• Be mindful of a...
The antidote to worrying about the
future is remaining in the present.
Questions? Thoughts? Concerns?
Thank you for your time and attention!
Fear of Recurrence for Breast and Ovarian Cancer Survivors
Fear of Recurrence for Breast and Ovarian Cancer Survivors
Fear of Recurrence for Breast and Ovarian Cancer Survivors
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Fear of Recurrence for Breast and Ovarian Cancer Survivors

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It is normal and common to experience fears about recurrence after finishing treatment for cancer. For some, the anxiety emerges only occasionally, whereas for others, the fears are persistent and interfere with their life and day-to-day functioning. In this webinar, Wendy Lichtenthal, Ph.D., discussed strategies for coping with fear of cancer recurrence, allowing time for questions and group discussion. Q&A period followed.

Publié dans : Santé & Médecine
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Fear of Recurrence for Breast and Ovarian Cancer Survivors

  1. 1. Fear of Recurrence for Breast and Ovarian Cancer Survivors A “Fear Management” (FM)Toolbox Wendy G. Lichtenthal, PhD AssistantAttending Psychologist, Department of Psychiatry & Behavioral Sciences Memorial Sloan KetteringCancer Center SHARE October 6, 2016
  2. 2. Why are you here today? Because This. Is. Hard.
  3. 3. Overview • What we know about fear of recurrence • Our group’s efforts to reduce fear of recurrence • What you can do for “fear management” (FM)
  4. 4. Fear of Cancer Recurrence: Survivors’ Most Common Concern • Rates range from 26% to as high as 99%, depending on measure used and group being examined • Fear commonly persists: even 5 years post-diagnosis, 70% -82% of cancer survivors may still experience fear of recurrence American Cancer Society, 2007; Baker et al., 2005; Cappiello et al., 2007; Hewitt et al., 2006; Hodgkinson et al., 2007; JohnsonVickberg, 2001; Koch et al., 2014; Mast, 1998; Mishel et al., 2005; Simard et al., 2013; Tewari & Chagpar, 2014
  5. 5. What do cancer survivors fear? It varies from one person to another. • Chemotherapy • Surgery • Radiation • Hospitalization • Physical changes • Loss of hair • Emotional distress • Pain • Advanced disease • Suffering of loved ones • Death JohnsonVickberg, 2001 Chemotherapy... worrying about my family…
  6. 6. Higher levels of fear of recurrence can be impairing • Associated with depression and reduced quality of life • Associated with increased body monitoring, medical visit anxiety, and general preoccupation with health Alfano & Rowland, 2006; Dandenau et al., 2007; Eismann et al., 2010; Hodgkinson et al., 2007; Koch et al., 2014; McEwen, 1998 ; Tewari & Chagpar, 2014; van den Beuken-van Everdingen et al., 2008
  7. 7. And fear of recurrence is challenging to manage…. even for professionals. • Beliefs are not irrational • In a survey of 64 psychosocial professionals, over 90% found managing fear of recurrence at least somewhat challenging • Over 99% were interested in further training in how to manage fear of recurrence Butow et al., 2013; Thewes et al., 2014
  8. 8. Despite this, few psychosocial interventions have been designed to specifically target fear of recurrence Butow et al., 2013; Humphris & Ozackinci , 2008; Mishel et al., 2005; Thewes et al., 2014
  9. 9. In fact, management of fear of recurrence is the number one unmet need of cancer survivors American Cancer Society, 2007; Baker et al., 2005; Hewitt et al., 2006; Hodgkinson et al., 2007; JohnsonVickberg, 2001; Mishel et al., 2005; van den Beuken-van Everdingen et al., 2008
  10. 10. Thus, there has been a compelling need to develop interventions that directly target fear of cancer recurrence JohnsonVickberg, 2001; Mishel et al., 2005; van den Beuken-van Everdingen et al., 2008
  11. 11. A PromisingTarget: Cognitive Biases • Being attentive toward threat is often normative and adaptive • Higher levels of anxiety may be maintained by cognitive biases, e.g., attention and interpretation biases • Vicious cycle: biases result in anxiety, and in turn, anxiety results in more biased information processing • Difficult to modify threat biases in survivors through talk therapy Bar-Haim et al., 2007; Butow et al., 2014; Glinder et al., 2007; Hewitt et al., 2006; Macleod et al., 1986; Kaur et al., 2013; Miles et al., 2009; Ouimet et al., 2009; Owens et al., 2004; van den Beuken-van Everdingen et al., 2008
  12. 12. Cognitive Bias Modification (CBM) • Novel, brief, computerized intervention approach • Rapid and repetitive computer tasks facilitate new automatic cognitive habits outside of one’s conscious awareness better than verbal methods • Can be administered in users’ homes, is cost-effective, easily disseminated, does not have the side effects of medication, does not require a trained therapist, and takes relatively little time • Can be personalized with a person’s strongest fears • Has promise for cancer survivors Amir et al., 2009; Beard et al., 2012; Hallion & Ruscio, 2011; Mogoase et al., 2014
  13. 13. g (T2 v. Control) * p ** g (T3 v. Control) * p** Experimental 0.35 .095 0.54 .005 * Hedges’ g effect sizes are standardized such that positive values represent improvement. ** Wald χ2 is derived from generalized estimating equations estimating the association between the group x time interaction and the outcome of interest (i.e., differences in change over time between the treatment groups and the control group). Sample sizes: Baseline: n=97 (Experimental: n=64 / Control: n=33) Post-Intervention: n=78 (Experimental: n=50 / Control: n=28) Follow-Up: n=75 (Experimental: n=49 / Control: n=26)
  14. 14. Conclusions from Study • Both versions of AIM-FBCR appear to improve health worries as compared to a placebo control condition; though the clinical significance of these findings is unknown • Limited by small, homogeneous sample; challenges with computer program; and completion of sessions at home, meaning less control of testing conditions • Plan is to create an “app” to improve ease of use and adapt for other cancer survivor populations Notebaert et al., 2014; Simard et al., 2013
  15. 15. So what can you do NOW for Fear Management (FM)?
  16. 16. Trials examining interventions for fear of recurrence • Conquer Fear (Butow et al., 2013): Ongoing RCT comparing 5-session individual intervention that uses blend of Meta-Cognitive Therapy and Acceptance and Commitment Therapy to relaxation • Worry Less and Live Well after CancerTreatment (WiLLoW) (Dunn, Shumay, et al., unpublished): RCT comparing 7-session Acceptance and Commitment Therapy group to treatment as usual • Beyond Fear [part of Survivors’ Worries of Recurrent Disease (SWORD)] (van der Wal et al., 2015): RCT comparing 5 face-to-face and 3 online/telephone sessions of CBT to treatment as usual • Mindfulness-based Stress Reduction (Lengacher et al., 2014): RCT comparing 6 sessions of MBSR to treatment as usual • Gratitude Letters (Otto et al., 2016): RCT comparing 6 letter writing sessions to an online writing control condition Butow et al., 2013; Humphris & Ozackinci , 2008; Mishel et al., 2005; Otto et al., 2016; Thewes et al., 2014
  17. 17. Create your own FM toolbox • Normalize and validate • Share and process • Make sense of your responses • Establish effective ways to communicate with your healthcare team • Use cognitive-behavioral techniques • Use mindfulness strategies • Redirect your attention • Find meaning in your life • Maintain COMPASSION
  18. 18. Normalize andValidate • Give yourself permission to feel • Use self-talk • Check in with a friend, trusted family member, or other survivors
  19. 19. Don’t underestimate the power of sharing
  20. 20. Process your feelings and make sense of your responses • Understand the context: we all bring our own – Personal cognitive schemas and worldviews – Past or ongoing life experiences and relationships • Express emotions in helpful ways • Discuss with others who are supportive • Journal
  21. 21. Be compassionate toward the lens through which you view the world
  22. 22. Establish effective ways to communicate with your healthcare team • What information do you need to know? (e.g., level of risk, when to contact team about symptoms, etc.) • What is your provider’s recommendation about surveillance? • When should you expect results after undergoing tests and scans? • What is the best way to reach the office when you have concerns? • What strategies do you think will get your needs met?
  23. 23. Cognitive-Behavioral Strategies van de Wal et al., 2015 My cancer is going to recur. Scared Avoidance, checking, reassurance- seeking
  24. 24. Consider your beliefs about your anxiety Self-Regulation of Executive Function (S-REF) Butow et al.., 2013; Butow et al., 2014 Fear of Cancer Recurrence Self-beliefs “I can’t handle this anxiety.” Meta-cognitions: Beliefs about the benefit and danger/ uncontrollability of worry “Worrying about cancer will help me be prepared for it.” “Worrying like this is going to make me sick.” Existential concerns “I don’t know what I should be focusing on in my life right now.”
  25. 25. Cognitive responses: Address distress with helpful thoughts • Reframe thoughts related to both the benefits and dangers of worrying • Come up with helpful responses • Minimize critical self-evaluation • Be compassionate toward your thoughts – understand but gently eliminate the “should's” • Ask yourself what kind words you would share with a friend or loved one in this situation
  26. 26. Change the meaning of the surges of anxiety • Temporary • Manageable • Natural
  27. 27. Behavioral responses: Address distress with helpful behaviors • Minimize avoidance where possible (including allowing thoughts as they emerge) • Choose helpful behaviors with healthcare providers: – What is my goal in this situation? – What actions or communication approaches are most likely going to help me achieve this goal? • Engage in pleasurable activities (keep a list to turn to!) • Engage in relaxation practices (deep and calming breathing; progressive muscle relaxation)
  28. 28. Mindfulness Strategies • Moment-to-moment, non-judgmental awareness: NOTICING • Pay attention to the present moment (including thoughts and feelings) as non-reactively and openheartedly as possible • Practice by concentrating on something, like your breath, using focused attention and your senses: notice its pace, sound, feel, temperature
  29. 29. Focus. Wander. Start over.
  30. 30. Leading with the mind: Using focused attention • Mindfulness meditation websites – http://www.mindful.org/meditation/mindfulness-getting-started/ – http://www.buddhanet.net/audio-meditation.htm – http://marc.ucla.edu/body.cfm?id=22 • Guided imagery • Apps like Breathe2Relax, Headspace, Buddify, Calm,Take a Break
  31. 31. Acceptance • Maintain compassion toward one’s thoughts • Allow them to “be”…try not to push them out • Redirect your attention to the here and now
  32. 32. Walking the fine line between… AcceptingYour Feelings while Redirecting Attention
  33. 33. Takes practice to work that “flexibility” muscle!
  34. 34. Leading with the body: Use your body to discharge and to bring you back to the here and now • Progressive muscle relaxation • Massage • Acupuncture • Exercise
  35. 35. Find meaning in your life • Write letters of gratitude to people in your life (Otto et al., 2016) • Make go-to lists to review during “moments”: – What are the activities and experiences that are most important to you? What can you engage in when anxiety surges? – What are the values you hold most dear? – Who do you want to be in the face of the challenge of fear of recurrence? • Find meaning in how you face challenging situations and the attitude you choose: The attitude you choose is what you always have control of
  36. 36. “Belief in a conditional world opens up the consideration of multiple possibilities since certainty is not absolute." Mishel, 1990 (p. 261) Mishel, 1990 For cancer survivors… “If everything’s okay next year, then…”
  37. 37. “Conditional” living can leave you feeling stuck…. “Figure Stuck betweenTwoWalls” byWilliamT. Ayton, 2009
  38. 38. So, how does one get “unstuck”? Image courtesy of suphakit73 at FreeDigitalPhotos.net
  39. 39. First, validate rather than criticize your feelings: this experience is HARD!
  40. 40. Then…
  41. 41. Consider the choice you have in how you create meaning.
  42. 42. “…everything can be taken from a man but one thing: the last of the human freedoms— to choose one’s attitude in any given set of circumstances…” Frankl, 1959/1984 Viktor E. Frankl, M.D., 1905-1997
  43. 43. RESPONSIBILITY Breitbart & Applebaum, 2011; Breitbart & Poppito, 2010; Frankl, 1959/1984 The ability to respond to the life you have been given.
  44. 44. COURAGE Breitbart & Applebaum, 2011; Breitbart & Poppito, 2010; Frankl, 1959/1984 Moving ahead in spite of uncertainty.
  45. 45. He who has a why to live for can bear almost any how. - Friedrich Nietzsche Frankl, 1959/1984
  46. 46. What areYOUR whys?
  47. 47. Fear Management (FM): Cultivating compassion toward yourself • Understand your personal context and lens • Be mindful of and compassionate toward your emotional responses • Develop a compassionate mantra or helpful response (“Of course I’m scared” or “Back to the moment” or simply, “Compassion”) • Practice staying in the moment, allowing feelings and thoughts to naturally rise and fall, coming back to the moment, and living life meaningfully
  48. 48. The antidote to worrying about the future is remaining in the present.
  49. 49. Questions? Thoughts? Concerns?
  50. 50. Thank you for your time and attention!

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