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Treatment aimed specifically at fear of recurrence works, and the effect is small: across 23 controlled trials the pooled difference was 0.33 of a standard deviation afterwards and 0.28 at follow-up. The two largest randomised trials, ConquerFear with 222 people and SWORD with 88, each beat their comparator, and SWORD cost 466 euros a person.
The meta-analysis first, because it sets the expectation. Twenty-three controlled trials, twenty-one of them randomised, were pooled in 2020. The effect on fear of recurrence was a Hedges's g of 0.33 (95 per cent confidence interval 0.20 to 0.46) immediately after treatment and 0.28 (0.17 to 0.40) at follow-up. Interventions the authors classified as contemporary cognitive behavioural therapies, which work on the process of thinking rather than its content, did better than traditional ones: g of 0.42 against 0.24. Group formats and shorter follow-up intervals were also associated with larger effects. A GRADE assessment rated the evidence moderate in strength. The authors' own summary is the honest one: "a small but robust effect at postintervention, which was largely maintained at follow-up".
ConquerFear is the larger trial. Survivors of curable breast or colorectal cancer or melanoma who had finished treatment two months to five years earlier, and who scored above the clinical cut-off on the severity subscale of the inventory, were randomly assigned to five face-to-face sessions of ConquerFear or to an attention control, a relaxation programme called Taking-it-Easy, so that the comparison was against time with a therapist rather than against nothing. ConquerFear combines attention training, work on metacognitions, acceptance and mindfulness, agreed screening behaviour and values-based goal setting. Of 704 potentially eligible survivors from 17 sites and two online databases, 533 were contactable and 222 consented, a 42 per cent consent rate; 121 were assigned to the intervention and 101 to control. The intervention group improved more on inventory total and severity scores immediately after therapy, and the difference on the total score was still present at six months. Several secondary outcomes improved immediately afterwards, including general anxiety, cancer-specific distress and mental quality of life.
SWORD tested a cheaper shape: blended therapy, five face-to-face sessions and three online. Eighty-eight survivors of breast, prostate or colorectal cancer with high fear, six months to five years after curative treatment, were randomised to blended therapy or care as usual. On the Cancer Worry Scale the mean difference was 3.48 points in favour of therapy (95 per cent confidence interval 2.28 to 4.69, p below 0.001), an effect size of 0.76. Thirteen of 45 people in the therapy arm (29 per cent) reached clinically significant improvement, against none of 43 in the control arm, and 30 of 42 (71 per cent) rated themselves improved against 12 of 38 (32 per cent). At fifteen months the difference had shrunk but had not gone: a mean difference of 1.787 points (95 per cent confidence interval 0.323 to 3.251, p equals 0.017). The economic analysis put the cost of delivering the therapy at 466 euros a person, total costs 631 euros lower than usual care with wide uncertainty, and an incremental cost-effectiveness ratio of 2,049 euros per quality-adjusted life-year, with a 62 per cent probability of being cost-effective at a willingness to pay of 20,000 euros per quality-adjusted life-year.
What this adds up to. Something specific can be done, it has been tested properly, and it is cheap. Two things temper that. The first is the size of the effect: a third of a standard deviation is a real difference and not a transformation, and the trials recruited people who had agreed to five or eight sessions of therapy about the thing they were most afraid of, which is a selected group. The second is availability. OnCo could not find a health service anywhere that commissions ConquerFear, blended therapy for fear of recurrence, or any equivalent as a named service with a referral route. The ASCO 2023 guideline recommends a stepped-care model and names cognitive behaviour therapy, behavioural activation, mindfulness-based stress reduction, acceptance and commitment therapy and structured physical activity for anxiety and depressive symptoms in survivors; it is the nearest thing to a route in, and fear of recurrence is not the condition it names.
What to do with that as a reader: the components are not secret. Agreeing a checking rule with the team rather than inventing one, deciding in advance what a scan appointment is for, and practising moving attention away from a sensation rather than arguing with it are the active ingredients of the trials, and they are what a therapist trained in the contemporary version will teach.
Contemporary cognitive behavioural therapies for fear of recurrence do not try to reduce the estimated probability of relapse, which would be dishonest and in many cases wrong. They work on the mechanics: attention training to loosen the grip of a bodily sensation, metacognitive work on beliefs that worry is uncontrollable or protective, acceptance of the uncertainty as a permanent feature, an agreed rule for checking and screening so that the behaviour is bounded, and goal setting that restores a future worth planning for.
Query for this technology: (TITLE:"Treating fear of recurrence: the randomised trials, their effect sizes, and where the treatment is available" OR ABSTRACT:"Treating fear of recurrence: the randomised trials, their effect sizes, and where the treatment is available") AND (cancer OR tumor OR tumour OR oncology OR carcinoma OR lymphoma OR leukemia OR leukaemia OR myeloma OR sarcoma OR melanoma OR glioma). Results are unfiltered search hits about Treating fear of recurrence: the randomised trials, their effect sizes, and where the treatment is available, not a curated reading list.
Shares Relaxation training and guided imagery, Mindfulness-based stress reduction and cognitive therapy, Fear that the cancer will come back: how common it is, and when it stops being ordinary worry, Getting psychological help after cancer: the stepped-care model, and what is actually commissioned and the tags rejuvenation, survivorship, psychosocial.
Shares Risk-stratified lifelong care for tens of millions of survivors, automated and shared with primary care, Mindfulness-based stress reduction and cognitive therapy, Getting psychological help after cancer: the stepped-care model, and what is actually commissioned, Cognitive behavioural therapy for fatigue and distress and the tags rejuvenation, survivorship, psychosocial.
Shares Mindfulness-based stress reduction and cognitive therapy, Placebo, Psycho-oncology and distress screening, Quality of life and the tags rejuvenation, survivorship, psychosocial.
Shares Risk-stratified lifelong care for tens of millions of survivors, automated and shared with primary care, Getting psychological help after cancer: the stepped-care model, and what is actually commissioned, Psycho-oncology and distress screening, Quality of life and the tags rejuvenation, survivorship, psychosocial.
Shares Fear that the cancer will come back: how common it is, and when it stops being ordinary worry, Getting psychological help after cancer: the stepped-care model, and what is actually commissioned, Psycho-oncology and distress screening, Quality of life and the tags rejuvenation, survivorship, psychosocial.
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Shares Psycho-oncology and distress screening, Quality of life, Survivorship and late effects are neglected, HR-positive / HER2-negative breast cancer and the tags rejuvenation, survivorship, psychosocial.
Shares Psycho-oncology and distress screening, Quality of life, Survivorship and late effects are neglected, HR-positive / HER2-negative breast cancer and the tags rejuvenation, survivorship, psychosocial.