September 2017 VOL 8, NO 9

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2017 American Psychosocial Oncology Society Annual Conference

Promising Results in Novel Intervention for Survivors Experiencing Anxiety at Reentry

Anxiety is a surprisingly common, chronic, and in many cases, unaddressed concern among cancer survivors, according to Joanna Arch, PhD, Assistant Professor in the Department of Psychology and Neuroscience at the University of Colorado Boulder. Anxiety among patients with cancer predicts lower quality of life, overutilization of medical care, and possibly cancer recurrence and earlier death. And the reentry phase—the time when a patient makes the transition from active care to posttreatment—is a particularly anxiety-provoking transition for many.

“When cancer survivors are followed over time, depression normalizes within a few years after treatment, but anxiety remains elevated for 10 or more years,” she said.

Dr Arch and colleagues developed a pilot study aimed at addressing anxiety in cancer survivors during the reentry phase and presented their results at the APOS Annual Conference.

The ACT Model

The investigators adapted the Assertive Community Treatment (ACT) model for anxious reentry-phase cancer survivors and designed one of the first known interventions developed specifically for broad anxiety, not just fear of recurrence, in cancer survivors at reentry.

The ACT model is a 6-sided service delivery model designed to provide comprehensive, locally based treatment to people with persistent mental illnesses. The model is built around 6 psychological processes—present moment, values, committed action, self as context, defusion, and acceptance—and promotes forms of coping that predict positive psychosocial outcomes among cancer survivors.

Dr Arch discussed these psychological processes and explained that the present moment emphasizes openness by allowing thoughts and feelings to come and go. Defusion refers to creating an adaptive psychological distance between oneself and the content of one’s thoughts, “particularly the unhelpful ones,” she noted. Self as context is the idea that all human beings have the potential to contact a transcendent sense of self, beyond seeing themselves as a collection of thoughts or feelings (ie, conceptualizing oneself as a tragic cancer victim vs a person who has experienced cancer), among other experiences. Values address who and what are most important to us as human beings—what makes us vital, alive, nourished, and fulfilled—and committed action is a commitment to meaningful behavior change.

Why This Intervention for This Set of Problems?

According to Dr Arch, studies have demonstrated that the ACT model (when compared with cognitive behavioral therapy) is a particularly good match for patients who experience broad emotional distress, and its effects are highly durable. “This is particularly important for cancer survivors,” she said. “We know that elevated anxiety tends to be a highly enduring problem among survivors, so we need a treatment with highly enduring effects.”

Cancer survivors often face realities that cannot be fully changed or influenced, and many survivors wrestle with existential concerns. Notably, the ACT model actually allows for, rather than minimizes, feelings of distress and fear associated with cancer. “Its emphasis on personal values—and acting in ways that align with those values in a way that gives one’s life meaning—is particularly well-positioned to deal with existential concerns,” she noted.

Significant Improvements in Anxiety and Depression

This single-arm pilot study enrolled 42 adult reentry-phase cancer survivors with elevated anxiety or depression symptoms in daily life, plus moderate to severe anxiety specifically about cancer. The study assessed the feasibility and preliminary efficacy of an ACT group intervention in this population and compared ACT with usual care in a statewide community cancer network.

The researchers made assessments during a month-long multiple baseline period—at mid-intervention, postintervention, and 3-month follow-up—and saw robust improvement across all outcomes. They noted the largest and most significant drops in anxiety and depression over the 3-month follow-up period. Besides behavioral avoidance, which was not prevalent in the sample, trauma symptoms related to cancer dropped significantly, as did fear of recurrence, and vitality scores improved. The investigators also saw moderate improvements in pain scores, an unexpected but favorable outcome, according to Dr. Arch.

Increases in cancer-related psychological flexibility—the capacity to actively accept thoughts and feelings about cancer and not allow them to dominate behavior—predicted subsequent change in most outcomes: depression, physical pain, traumatic impact of cancer, vitality, and life meaning. It also nearly predicted change in anxiety and life comprehensibility, but not fear of recurrence.

According to the researchers, these promising results warrant further investigation. They are currently conducting a randomized controlled trial to compare ACT with usual care for anxious cancer survivors at reentry, and they are also adapting ACT to address the psychological needs of patients with advanced cancer.

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