Photo Credit: istock.com/Nadiia Lapshynska

In this discussion, Dr. Shelly Johns, a clinical health psychologist and cancer researcher, emphasizes the importance of physicians routinely addressing fear of cancer recurrence (FCR) in patient conversations. She highlights that normalizing and validating these concerns can improve patient well-being and that cognitive behavioral therapies, including mindfulness and values-based approaches, are effective interventions. Encouraging survivors to focus on present-moment awareness, clarify personal values, and adopt healthy lifestyle changes can help them manage FCR. She also discusses Acceptance and Commitment Therapy (ACT), which helps patients acknowledge their fears without being controlled by them, allowing them to live meaningful lives despite ongoing concerns about recurrence.

Research Highlight

FCR is a persistent psychological concern for many individuals with breast cancer (PwBC), impacting emotional, behavioral, cognitive, relational, and professional aspects of life. The study conducted by Dr. Johns and colleagues analyzed open-ended survey responses from 390 PwBC in a randomized controlled trial (RCT) on FCR, revealing that while most patients identified coping strategies, those with higher FCR tended toward avoidant coping. Many sought ways to regain a sense of purpose, belonging, and control. The findings highlighted the need for clinicians to routinely discuss FCR with survivors, providing education on actual recurrence risks and strategies to improve coping, ultimately enhancing quality of life.

Transcript: 
I’m Shelly Johns. I’m a board certified clinical health psychologist and an associate professor of medicine at the Indiana University School of Medicine. And I’m also a research scientist at the Regenstrief Institute in the Center for Health Services Research. There. I have worked in cancer care since 1996, and I have been both a clinician working directly with individuals with cancer. And then I’m also a cancer researcher testing supportive interventions to improve quality of life for cancer adults with cancer. I invite my physician colleagues to routinely ask about fear of recurrence by using simple open-ended questions like, do you have any worries about your cancer coming back? Or How are you feeling about the possibility of cancer coming back? I realize these questions do take time, which is very difficult in a busy healthcare session yet I think that these, asking these questions can sometimes save time in the long run because then targeted interventions can be offered to those who need them.

I just want to emphasize the importance of normalizing and validating people’s concerns about their cancer possibly coming back regardless of what their actual risk of recurrence is. It’s a natural emotion to be concerned about their cancer coming back and having to go through treatment again. So recent meta-analysis of fear of recurrence interventions have shown that cognitive behavioral therapies, both the traditional ones as well as the more modern ones that incorporate mindfulness and values-based action, that those tend to be very effective solutions for addressing fear of recurrence. So some of the specific coping skills within those frameworks would include things like mindfulness-based practices, which invite survivors to really focus on this present moment of their lives rather than getting too caught up about the past or the future where a lot of that anxiety or a lot of that distress comes from. And so mindfulness can be really super helpful.

We also have found that just noticing and acknowledging our thoughts and our feelings without getting caught up in them, that can be really helpful, too. One of the ways that we can do that is supporting our survivors in clarifying what they want their lives and their survivorship to be about what is most meaningful and purposeful for them in their lives so that then they can focus their time and their energy on pursuing those activities as opposed to just worrying about their cancer coming back. It’s always important to support our survivors in adopting healthy lifestyle practices, whether that’s increasing their physical activity or increasing fruits and vegetables in their diets, decreasing the amount of alcohol or tobacco, tobacco cessation. Those are some things that can be really helpful and can give survivors a focus of something, an actionable thing or action that they can take in order to potentially reduce their risk of recurrence.

One of the interventions that we’re testing in the study that’s ongoing right now is an intervention that’s called Acceptance and Commitment Therapy. It’s a modern form of cognitive behavioral therapy that incorporates mindfulness. It incorporates awareness of thoughts and feelings without getting hooked by them. And it also incorporates values clarification and then setting values-based action goals. And what I mean by that is clarifying what a survivor most wants their life to be about. So for instance, some of our survivors really want to focus on being a loving and involved parent. Other survivors want to be taking actions that are really enriching their spirituality. Other survivors really are focused on doing meaningful and enriching work through their jobs, through their professions. And we have been finding that survivors who really focus on pursuing their values, that is something that really gives their survivorship more meaning and sense of purpose. And then they just bring their fear of recurrence with them for the ride of their lives. They don’t let their fear disable them or keep them stuck sitting in a chair just worrying.