Tauber Et Al. (2019) - Effect of Psychological - Recurrence

Effect of Psychological Intervention on Fear of
review articles
Cancer Recurrence: A Systematic Review
and Meta-Analysis
Nina M. Tauber, MSc1,2; Mia S. O’Toole, MSc, PhD1; Andreas Dinkel, DSc2,3; Jacqueline Galica, PhD2,4; Gerry Humphris, PhD2,5;
Sophie Lebel, PhD2,6; Christine Maheu, PhD2,7; Gozde Ozakinci, PhD2,5; Judith Prins, MSc, PhD2,8; Louise Sharpe, MS, PhD2,9;
Allan “Ben” Smith, PhD2,10; Belinda Thewes, PhD2,9; Sébastien Simard, PhD2,11; and Robert Zachariae, DMSc1,2,12
abstract
PURPOSE Fear of cancer recurrence (FCR) is a significantly distressing problem that affects a substantial number
of patients with and survivors of cancer; however, the overall efficacy of available psychological interventions on
FCR remains unknown. We therefore evaluated this in the present systematic review and meta-analysis.
METHODS We searched key electronic databases to identify trials that evaluated the effect of psychological
interventions on FCR among patients with and survivors of cancer. Controlled trials were subjected to meta-
analysis, and the moderating influence of study characteristics on the effect were examined. Overall quality of
evidence was evaluated using the GRADE system. Open trials were narratively reviewed to explore ongoing
developments in the field (PROSPERO registration no.: CRD42017076514).
RESULTS A total of 23 controlled trials (21 randomized controlled trials) and nine open trials were included. Small
effects (Hedges’s g) were found both at postintervention (g = 0.33; 95% CI, 0.20 to 0.46; P , .001) and at follow-
up (g = 0.28; 95% CI, 0.17 to 0.40; P , .001). Effects at postintervention of contemporary cognitive behavioral
therapies (CBTs; g = 0.42) were larger than those of traditional CBTs (g = 0.24; b = .22; 95% CI, .04 to .41; P =
.018). At follow-up, larger effects were associated with shorter time to follow-up (b = 2.01; 95% CI, 2.01 to
2.00; P = .027) and group-based formats (b = .18; 95% CI, .01 to .36; P = .041). A GRADE evaluation indicated
evidence of moderate strength for effects of psychological intervention for FCR.
CONCLUSION Psychological interventions for FCR revealed a small but robust effect at postintervention, which
was largely maintained at follow-up. Larger postintervention effects were found for contemporary CBTs that were
focused on processes of cognition—for example, worry, rumination, and attentional bias—rather than the
content, and aimed to change the way in which the individual relates to his or her inner experiences. Future trials
could investigate how to further optimize and tailor interventions to individual patients’ FCR presentation.
J Clin Oncol 37:2899-2915. © 2019 by American Society of Clinical Oncology
Licensed under the Creative Commons Attribution 4.0 License
INTRODUCTION FCR is among the most commonly reported concerns

Despite improved treatments and prognoses, many by survivors of cancer and often their most frequently
survivors of cancer face the possibility that their cancer endorsed unmet need.6 A comprehensive review2 es-
may return. For some, uncertainty leads to high levels timates that, across different cancers, 22% to 87% of
of fear of cancer recurrence (FCR), which is defined as survivors of cancer report moderate to high FCR, and
the “fear, worry, or concern about cancer returning or 0% to 15% report high or clinical levels of FCR, al-
ASSOCIATED
CONTENT progressing.”1(p424) Individuals with active disease may though there currently is no agreed upon clinical cutoff.
Data Supplement fear that stable disease will progress, and survivors of Furthermore, FCR seems to remain relatively stable over
Author affiliations cancer have been found to fear recurrence after time.2,7 Associations have been reported between FCR
and support
completion of active treatment.2 Such fears and and depression, poorer quality of life, and impaired
information (if
worries can thus be present from the beginning of functioning,4,8 and a growing body of evidence suggests
applicable) appear
diagnosis and continue throughout treatment and the that people with high FCR may both overuse health
at the end of this
article. survivorship trajectory. It is common to experience services and avoid appropriate tests to identify re-
Accepted on July 1, some degree of FCR, and transitory or low levels of currence in a timely fashion.9 These results emphasize
2019 and published at FCR may even be adaptive, alerting the patient to signs the need for effective, evidence-based treatments
jco.org on
of new or recurring cancer and encouraging positive for FCR.
September 18, 2019:
DOI https://doi.org/10. health behaviors.3,4 Persistent and excessive fear, Interventions for FCR are emerging and the number
1200/JCO.19.00572 however, can be highly debilitating.1,2,5 of randomized controlled trials (RCTs) that have
Volume 37, Issue 31 2899

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Tauber et al
evaluated such interventions is expanding rapidly. A recent related to cancer (eg, neoplasm or oncology) were combined
review10 identified five RCTs of FCR interventions that were with keywords related to intervention (eg, psychotherap* or
published in 2016 and 2017 alone, and several study “cognitive-behav* therap*” or “psychol* treatment”) and
protocols and feasibility studies have been published terms related to fear (anxiet* or worr* or fear* or concern)
during this period.11-18 The exact number of existing psy- and recurrence (relapse or recur* or progress*). The full
chological interventions for FCR has not been systemati- search string is shown in the Data Supplement. Searches
cally identified, and little is known about their efficacy in were conducted for the period from the earliest time available
alleviating FCR symptoms. Thus far, only one meta- until June 2018, together with backward searches (snow-
analytical evaluation of the effect of mind–body inter- balling) of reference lists of identified articles and earlier
ventions on FCR and cancer-related uncertainty in 19 systematic reviews and forward searches (citation tracking).
RCTs has been published,19 which reported a small effect
both at postintervention (Hedges’s g = 20.36; P , .001) Selection Procedure and Data Extraction
and at follow-up (g = 20.31; P , .001). However, this study English language reports published in peer-reviewed
included not only psychological interventions, but also sources were included. We assessed study eligibility us-
physical interventions—for example, yoga or dance. Sec- ing the PICO approach (population, intervention, com-
ond, only 13 of the 19 studies included an FCR-specific parison, and outcome).26
measure, with the remaining studies assessing more
Population: adult patients with or survivors of cancer (age
general cancer-related uncertainty. Although cancer-
18 years or older). Studies of children and adolescents
related uncertainty overlaps with FCR,20-23 uncertainty
with cancer, patients without current cancer or
does not necessarily pertain to the perceived risk of re-
a cancer history, or caregivers of patients with cancer
currence or progression, but can also relate to other issues
were excluded.
that are associated with cancer diagnosis and treatment,
Intervention: any psychological intervention that con-
including work-related issues or symptom management.
sisted primarily (. 50%) of psychological methods—
Third, potentially important between-study differences
for example, cognitive-behavioral, psycho-educative,
remained unexplored in the former review,19 including the
imagery-based, and meditative approaches. In-
type of psychotherapeutic framework and whether the
terventions that involved physical approaches—for
intervention specifically targeted FCR. Finally, the number
example, yoga or exercise—could be included in the
of FCR interventions being developed and evaluated is
intervention but only if they were a secondary com-
rapidly expanding, and not all relevant studies were in-
ponent (, 50%). Interventions were not required to
cluded in the former review. Taken together, attempts to
directly target FCR.
synthesize the literature on psychological interventions for
Comparison: Eligible studies were required to use
FCR are limited, and an up-to-date review of current de-
a control group—for example, waitlist, treatment as
velopments in the field is lacking.1
usual, or attention/active control. Case studies, studies
The primary objective of the current study was to conduct that included only two active psychological in-
a systematic review and meta-analysis of the efficacy of terventions and no control group (eg, noninferiority
psychological interventions for alleviating FCR among pa- trials), and open trials that employed uncontrolled
tients with and survivors of cancer as evaluated in controlled pre–post designs were excluded from the meta-
trials. We hypothesized that psychological interventions are analysis. OTs, however, were included in the narra-
efficacious in reducing FCR symptoms. A secondary aim tive systematic review.
was to explore the possible influence of between-study Outcome: pre- and postintervention data, or pre–post
differences in psychotherapeutic framework, treatment change score data on one or more quantitative FCR-
format, intervention dose, cancer type, patient characteris- relevant construct. FCR could be both primary and
tics, study design, and risk of bias. Finally, to explore current secondary outcome. Only measures that pertained to
developments in the field, we aimed to conduct a narrative concerns about the return or progression of cancer
evaluation of open trials (OTs) and noninferiority trials. were included. Studies that used qualitative assess-
ments, quantitative measures at one time point only,
METHODS or only measures of general anxiety or worry were
excluded. Studies needed to report results as either
The current study was conducted in accordance with
pre–post means and standard deviation/SE in all
the Preferred Reporting Items for Systematic Reviews and
groups, change scores in all groups, effect sizes (ESs;
Meta-Analyses (PRISMA) guidelines and was preregistered
eg, Cohen’s d or eta2), or provide other data that could
with PROSPERO (registration no.: CRD42017076514).25
be converted to an ES.
Search Strategy One author removed duplicates (A.B.S.) and five authors
We conducted keyword-based searches in PubMed, Psy- (N.M.T., J.G., A.B.S., B.T., and S.S.) took turns in pairs,
cINFO, Cochrane, CINAHL, and Embase databases. Keywords each screening one third of the records and ensuring that
2900 © 2019 by American Society of Clinical Oncology Volume 37, Issue 31

Psychological Intervention For Fear of Cancer Recurrence
all records were independently evaluated by two authors. “random sequence allocation”, “allocation concealment”,
Full texts of the remaining references were evaluated and “blinding of outcome assessment”, “accounting for attri-
reasons for exclusion registered (Data Supplement). Dis- tion”, and “selective reporting”. We further differentiated
agreements were discussed with a third author (N.M.T., “other sources of bias” with three subdomains: “treatment
B.T., or S.S.) until a negotiated conclusion was reached. integrity” (ie, therapist training and fidelity), “conflict of
Data were extracted by one author (N.M.T.) and checked interest” (ie, the trial was conducted by the therapists and/
by another author (C.M.). Studies were coded according to or the original developers of the therapy), and “bias in
a priori–specified characteristics, including study, in- sampling and dropout” (eg, convenience sampling and
tervention, participant characteristics, and risk of bias. uneven dropouts in intervention and control groups). Two
authors (L.S. and G.O.) performed ratings independently.
Computing ESs
Disagreements were discussed with a third author (N.T.)
Hedges’s g, a variation of Cohen’s d,27 correcting for pos- until a negotiated final rating was reached for each study.
sible bias as a result of small sample sizes,28 was used as Before the negotiation of a final rating, independent ratings
the standardized between-group ES. Whenever possible, were subjected to inter-rater reliability analyses (inter-rater
ESs were computed using means and their standard de- agreement and k statistics).39 Risk of bias scores were
viations for preintervention, postintervention, or change calculated for each study by evaluating the risk of bias for
scores. If unavailable, ESs were estimated on the basis of every item above as low, unclear (or not applicable), or high
other reported statistics—for example, P values, F values, risk, rated as 0, 1, and 2, respectively. Associations be-
or B values. Pooled ESs were weighted by the inverse SE, tween ESs and risk of bias scores were explored using
taking into account the precision of each study. The N used meta-regression. Risk of bias scores were not used as
in the calculation was the N in the final analysis. A random weights when calculating aggregated ESs, as this is dis-
effects model was chosen for all analyses, with positive couraged because of the risk of inducing bias.40
values indicating ESs in the hypothesized direction. If
studies reported results for more than one measure per Analytical Strategy
outcome, the independence of results was ensured by OTs and noninferiority trials were descriptively reviewed,
averaging ESs across all outcomes so that only one result and controlled trials (CTs) were subjected to meta-analysis
per study was used for each quantitative data synthesis. to determine the pooled overall ES. Pooled ESs from
Heterogeneity baseline to post-treatment results and follow-up results
were calculated separately. If multiple follow-up assess-
Heterogeneity was explored using Q and I2 statistics.29
ments were included, the longest follow-up assessment
Because of the generally low statistical power of hetero-
was chosen. Moderation analyses were performed with
geneity tests, a more liberal P value of # .10 was used to
meta-regression on the basis of random-effects models and
determine significant heterogeneity.30 The I2 statistic is an
were estimated using the maximum likelihood method
estimate of the variance in a pooled ES that is accounted for
when data were available for 10 or more studies. Analyses
by heterogeneity in the sample of studies and is unaffected
were conducted using Comprehensive Meta-Analysis ver-
by the number of studies (K).31 I2 values of 0%, 25%, 50%,
sion 3 (http://www.meta-analysis.com).
and 75% are taken to indicate no, low, moderate, and high
heterogeneity, respectively. We used the Grading of Recommendations Assessment,
Development and Evaluation (GRADE) system41 to rate the
Publication Bias
quality of evidence of the meta-analytic results. Quality of
Positive and negative findings are not equally likely to be evidence was graded as high, moderate, low, or very low.
published, and publication bias is a widespread problem GRADE uses a baseline rating of high for RCTs and low for
when reviewing available evidence.32 We evaluated pub- non-RCTs. This rating can be downgraded or upgraded on
lication bias using funnel plots and Egger’s test.33-35 If re- the basis of eight assessment criteria, including risk of bias,
sults indicated possible publication bias, adjusted ESs were inconsistency of results, indirectness, imprecision, publi-
calculated using the Duval and Tweedie trim-and-fill cation bias, effect magnitude, dose-response gradient, and
method.36 In the case of statistically significant results, we the effect of all plausible confounding factors that would
calculated the failsafe number33,37 —that is, the number of reduce the effect or suggest a spurious effect when no
unpublished studies with null findings that would reduce effect is found. Ratings were conducted and negotiated by
the results to statistical nonsignificance (P . .05)—and two authors (M.S.O. and R.Z.).
evaluated the robustness of results by comparing the
failsafe number with the suggested criterion (5K + 10).37
RESULTS
Risk of Bias Assessment The study selection process with reasons for exclusion
We adapted the Cochrane Collaboration tool38 to evaluate is described in Figure 1 and the Data Supplement.
the risk of bias within the context of psychological in- The literature search yielded 1,394 references, of which
tervention studies. We included the original domains of 32 independent studies were subjected to descriptive
Journal of Clinical Oncology 2901

Tauber et al
evaluation. Of these, 23 CTs were subjected to meta- thoughts and beliefs.73,74 Contemporary CBTs were defined
analytic evaluation. as interventions that were focused on the processes, rather
than the content of cognition—for example, worry, rumi-
CT Characteristics nation, attentional bias, and cognitive fusion—and aimed to
Study characteristics are listed in Table 1. The 23 CTs change the way in which the individual related to his or her
included a total of 2,965 patients with a mean sample size inner experiences.75-77 The remaining six interventions—
of 129.42-60,62-64 Of these, 21 studies reported post- other interventions—varied too much to be meaningfully
treatment data, with 16 of these reporting relevant grouped (eg, as psychodynamic therapy or supportive
follow-up data. Two additional studies reported long-term therapy). Approximately one half of interventions were
(follow-up) data only. Post-treatment data were analyzed for group based (K = 13), with the remaining using an indi-
2,163 participants. Follow-up data were obtained 29 weeks vidual format (K = 12). In most studies, interventions were
on average after intervention and were analyzed for 2,044 delivered face to face (K = 19). Number of sessions ranged
participants. Most studies were RCTs (K = 21), with most from one to 15 (mean, 6.6). Reducing FCR was the primary
control groups receiving no therapist attention (K = 19). Of aim in eight studies only.
the eight studies with FCR as the primary target of the
intervention, FCR severity was an inclusion criterion in four OT Characteristics
studies only. All but one study were conducted in Western
Nine OTs were eligible for descriptive evaluation (Table 1).
countries, participants were predominantly white, and, in
All studies were described as feasibility or pilot studies and
most studies, the majority of participants were women (K =
had sample sizes that ranged from eight to 56 (mean,
21). Breast cancer was the most frequent cancer diagnosis
29.1). FCR severity was the inclusion criterion in three
(K = 15) and, in the majority of studies (K = 18), participants
studies. Samples included prostate, breast, ovarian, and
had no evidence of disease.
mixed types of cancer, with participants in three studies
The 23 CTs evaluated a total of 25 interventions. Ten in- having current cancer. Five interventions could be cate-
terventions used a traditional cognitive behavioral therapy gorized as traditional CBTs and the remaining four as
(CBT) framework and nine interventions were contempo- contemporary CBTs. Five interventions had a primary aim
rary CBTs. Studies were categorized as traditional CBT of reducing FCR. Intervention was delivered in groups in
when interventions adhered to traditional cognitive be- four studies, all but three interventions were delivered face
havioral principles that focus not only on Beckian therapy, to face, and the number of sessions ranged from one to 10
but also on cognitive therapy principles that rely on in- (mean, 5.7). Eight studies reported positive statistically
formation processing models in which the individual is significant small-to-large within-subject ESs (range:
assumed to hold biases, which gives rise to dysfunctional Hedges’s g = 0.33-3.15).18,65-67,69,71,72 The remaining study
Records identified
Records identified in databases
through other sources
(n = 1,384)
(n = 10)
Records screened after

Records excluded
duplicates removed
(n = 823)
(n = 926)
Full-text articles assessed Records excluded (n = 71)

for eligibility Gray literature (n = 39)
(n = 103) FCR not an outcome (n = 26)
Language other than English (n = 3)
Overlap with included paper (n = 2) FIG 1. Study selection flowchart. FCR, fear
Design not relevant (n = 1) of cancer recurrence.
Independent studies included Studies excluded from

in descriptive evaluation meta-analysis
(n = 32) (n = 9)
Studies included
in meta-analysis
(n = 23)

TABLE 1. Study Characteristics
Cancer Type; Study FCR Severity as Delivery Mode; No. of Treatment Format;
Cancer Present Demographic Design; No. Inclusion Criteria; FCR Sessions; Duration, Initial No.; Analyzed No.
Study (country) (yes/no); Stage Characteristics of Arms FCR Measure Intervention Type* as Primary Outcome Weeks (FU)† (post, FU)
Controlled trials
42
Cameron (New Breast Mean age, 50.7 years CT CWS Contemporary CBT No Face to face Group
Zealand)
Journal of Clinical Oncology

Yes 94.2% white 2 No 12 154
NR* 100% female 16 (52) (72, 70)
75.7%
partnered
Lengacher43 (United Breast Mean age, 57.5 years RCT CARS Contemporary CBT No Face to face Group
States)
No 72.6% white 2 No 6 84
Stage 0-3 100% female 7 (82, no FU assessment)
% partnered = NR
Herschbach44 Mixed Mean age, 53.7 years CT FoP-Q Traditional CBT Yes Face to face Group
(Germany)
Yes % white = NR 3 Other Yes 4 265
Mixed 83% female 3 (55) (253, 253)
77.9% partnered
Shields45 (United Breast Mean age, 44.1 years RCT CARS Traditional CBT No Face to face Individual
States)
No 97.5% white 2 No 1 45
Stage 1-3 100% female 5 (14) (44, 44)
% partnered = NR
Crane-Okada46 Breast Mean age, 65.6 years RCT FCQ Contemporary CBT No Face to face Group
(United States)
No 79% white 2 No 12 49
NR 100% female 12 (18) (41, 41)
41.7% partnered
Heinrichs47 Breast or Mean age, 52.2 years RCT FoP-Q Traditional CBT No Face to face Group
(Germany) gynecologic

Yes % white = NR 2 No 4 90
Stage 1-3 100% female 8 (69) (72, 72)

100% partnered
Humphris48 (United Oropharyngeal Mean age, 58.8 years RCT WOC Traditional CBT No Face to face Individual
Kingdom)
No % white = NR 2 Yes 6 90
Mixed 29% female 17 (39) (87, 87)
% partnered = NR
(continued on following page)
2903
TABLE 1. Study Characteristics (continued)
49
Germino (United Breast cancer Mean age, 44 years RCT CARS Traditional CBT No Self-directed Individual
States)
No 62.6% white 2 No 4 313
Stage 1-4 100% female 22 (39) (no postassessment,
313)
% partnered = NR
50
Bannaasan Breast Mean age, 51.7 years RCT CARS – Other No Face to face Group
(Thailand) overall
fear
Stage 1-3 100% female 2 (6) (59, 59)
2904 © 2019 by American Society of Clinical Oncology

73.4% partnered
Bower51 (United Breast Mean age, 46.8 years RCT QLACS Contemporary CBT No Face to face Group
States)
No 76.1% white 2 No 6 71
NR 100% female 8 (19) (71, 71)
64.6% partnered
Dodds52 (United Breast Mean age, 55.3 years RCT FCRI Contemporary CBT No Face to face Group
States)
No 82.1% white 2 No 8 33
1-4 100% female 8 (12) (28, 28)
Tauber et al
42.9% partnered
Sterba53 (United Breast Mean age, 55.6 years RCT ASC Other No Self-directed Individual
States)
No 70% white 2 No 1 92
64% partnered
54
Dieng (Australia) Melanoma Mean age, 56.6 years RCT FCRI Other No Telephone Individual

No % white = NR 2 No 6 164
Stage 0-2 45% female 6 (31) (151, 151)
84.8% partnered

Lengacher55 (United Breast Mean age, 56.6 years RCT CARS Contemporary CBT No Face to face Group
States)
No 69.4% white 2 No 6 322
Stage 0-3 100% female 6 (12) (299, 299)
64.4% partnered
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56
Otto (United States) Breast Mean age, 56.9 years RCT CARS – Other No Online, self-directed Individual
overall
fear and
death

worries
No 86.6% white 2 Yes NR 67
Stage 0-4 100% female 6 (no postassessment,
67)
95.5% partnered
57
Merckaert Breast Mean age, 50.6 years RCT FCRI Traditional CBT No Face to face Group
(Belgium)
Stage 1-3 100% female 26 (159, no FU
assessment)
44% partnered
Butow58 (Australia) Mixed Mean age, 52.8 years RCT FCRI Contemporary CBT Yes Face to face Individual
Stage 0-4 95% female 10 (23) (173, 173)
62% partnered
59
Lichtenthal (United Breast Mean age, 55.2 years RCT CARS Traditional CBT No Computerized Individual
States)
No 73.7% white 2 Yes 8 110
Stage 0-3 100% female 8 (21) (110, 100)
60.3% partnered
Manne60 (United Gynecologic Mean age, 55.3 years RCT CARS – Traditional CBT No Face to face Individual
States) overall fear
Yes 79.0% white 3 Other No 7 352
Stage 1-4 100% female 9 (79) (352, 352)

67.3% partnered
61
van de Wall (the Mixed Mean age, 58.8 years RCT CWS, Traditional CBT Yes Face to face, online Individual

Netherlands) FCRI
NR 53% female 13 (88, no FU assessment)
82.9% partnered
2905
62
Victorson (United Prostate Mean age, 70.2 years RCT MAX-PC– Contemporary CBT No Face to face Group
States) FCR
Yes 95.1% white 2 No 8 43
NR 0% female 8 (12) (38, 31)
82.7% partnered
Gonzalez- Breast Mean age, 49.4 years RCT FCRI – Contemporary CBT No Face to face Group
Hernandez63 triggers,
(Spain) distress,
coping and
insight
2906 © 2019 by American Society of Clinical Oncology

Stage 1-4 100% female 8 (26) (56, 56)
% partnered = NR
Tomei64 (Canada) Mixed Mean age, 55 years RCT FCRI Traditional CBT Yes Face to face Individual
No 95.8% white 2 Yes 6 25
Stage 1-3 100% female 6 (19)‡ (24, 24)
79.2% partnered
Open trials
65
Chambers Prostate Mean age, 67 years OT MAX-PC- Contemporary CBT No Face to face Group
Tauber et al
(Australia) FCR
NR 0% female 8 (21) (12, 12)
84% partnered
Lebel66 (Canada) Breast, ovarian Mean age, 54.8 years OT FRQ Traditional CBT Yes Face to face Group
No 80.8% white 1 Yes 6 56

Stage 1-3 100% female 6 (19) (41, 37)
58.9% partnered

Seitz67 (Germany) Mixed Mean age, 27.3 years OT FoP-SF Traditional CBT No Online Individual
NR 70% female 5 (18) (20, 14)
50% partnered
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68
Smith (Australia) Mixed Mean age, 48 years OT FCRI Contemporary CBT Yes Face to face Individual
NR 100% female 10 (18) (7, 2)

75% partnered
Arch69 (United Mixed Mean age, 53.52 years OT CARS – Contemporary CBT No Face to face Group
States) overall fear
No 97.4% white 1 No 7 42
Stage 0-4 92.9% female 8 (21) (NR)
61.5% partnered
Momino70 (Japan) Breast Mean age, 55 years OT CARS Traditional CBT No Face to face Individual
78% partnered
Lengacher71 (United Breast Mean age, 57 years OT CARS Contemporary CBT No Online Individual
States)
No 93% white 1 No 6 15
80% partnered
Savard72 (Canada) Mixed Mean age, 57.7 years OT FCRI Traditional CBT No Face to face Group
Yes 100% white 1 Yes 4 38
NR 94.7% female 8 (38)
57.9% partnered
Davidson18 (United Breast Mean age, 60.0 years OT FCRI Traditional CBT Yes Telephone Individual
Kingdom)
No 1 Yes 1 16
Stage 1-3 N/A (1) (12)

Abbreviations: ASC, Assessment of Survivor Concerns; CARS, Concerns About Recurrence Scale; CBT, cognitive behavioral therapy; CT, controlled trial; CWS, Cancer Worry Scale; FCQ, Fear of
Recurrence Scale; FCRI, Fear of Cancer Recurrence Inventory; FoP-Q, Fear of Progression Questionnaire; FoP-Q-SF, Fear of Progression Questionnaire–Short Form; FRQ, Fear of Recurrence

Questionnaire; FU, follow-up; MAX-PC-FCR, Fear of Cancer Recurrence Subscale of the Memorial Anxiety Scale for Prostate Cancer; N/A, not available; NR, not reported; OT, open trial; QLACS, Quality of
Life in Adult Cancer Survivors; RCT, randomized controlled trial; WOC, Worry of Cancer Scale.
*Interventions were classified into psychotherapeutic traditions on the basis of the strategies described. If an intervention combined strategies from more traditions, the intervention was assigned the
psychotherapeutic tradition to which the strategies primarily belonged. If there was an insufficient description of therapies, original treatment protocols or studies were consulted. Classification was
conducted by two authors and agreement was reached by discussion.
†Intervention duration: time from pre- to postassessment and time to FU.
‡Data for intervention and controls combined at follow-up.
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Tauber et al
TABLE 2. Pooled Postintervention and Follow-Up Effects of Psychological Interventions on Fear of Cancer Recurrence Among Survivors of
Cancer
Sample
Size Heterogeneity* Global Effect Size
Effect K No. Q df P I2 Hedges’s g† 95% CI P Failsafe No.‡ Criterion§

Postintervention
Overall combined effect 21k 2,163 38.9 20 .007 48.6 0.33 0.20 to 0.46 , .001 255 115
Cancer type: breast 12 1,067 24.2 11 .012 54.5 0.34 0.14 to 0.53 .010 64 70
Cancer type: other/mixed 9 1,096 14.4 8 .071 44.6 0.32 0.15 to .49 , .001 54 55
Cancer present 5 659 9.4 4 .050 57.8 0.27 0.03 to 0.52 .031 9 35
Disease free 16 1,504 26.6 15 .032 43.6 0.35 0.21 to 0.50 , .001 150 90
Study design: RCT 19 1,848 30.6 18 .032 41.2 0.33 0.20 to 0.46 , .001 200 105
Study design: CT 2 315 6.5 1 .011 84.7 0.36 20.30 to 1.02 .283 — —
Format: individual 9 949 14.7 8 .066 45.5 0.28 0.09 to 0.47 .003 29 55
Format: group 12 1,214 24.1 11 .012 54.4 0.37 0.19 to 0.55 , .001 98 70
Delivery: face to face 18 1,835 32.6 17 .013 47.9 0.38 0.24 to 0.51 , .001 234 110
Delivery: other 3 328 3.1 2 .204 37.2 0.10 20.19 to 0.38 .510 — —
FCR as primary target 8 908 20.0 7 .006 65.0 0.44 0.20 to 0.67 , .001 68 50
FCR as secondary target 13 1,255 18.0 12 .116 33.3 0.26 0.12 to 0.41 , .001 50 75
FCR level as inclusion criterion 4 544 8.9 3 .030 66.5 0.36 0.09 to 0.64 .010 13 30
FCR level not inclusion criterion 17 1,641 28.8 16 .025 44.5 0.32 0.17 to 0.46 , .001 137 95
Therapy: traditional CBT 9 1,025 11.7 8 .116 31.5 0.24 0.08 to 0.39 .003 25 55
Therapy: contemporary CBT 9 848 6.1 8 .642 0.0 0.42 0.29 to 0.56 , .001 66 55
Therapy: other 3 290 15.0 2 .001 86.6 0.35 20.32 to 1.02 .310 — —
FCR measure: CARS 6 792 13.4 5 .020 62.7 0.38 0.15 to 0.61 .001 28 40
FCR measure: FCRI 7 659 8.3 6 .216 27.8 0.33 0.10 to 0.55 .005 22 45
Follow-up
Overall combined effect 18 2,044 26.8 17 .061 36.6 0.28 0.17 to 0.40 , .001 158 100
Cancer type: breast 11 1,109 13.9 10 .176 28.2 0.36 0.20 to 0.52 , .001 77 65
Cancer type: other/mixed 7 936 10.9 6 .091 45.1 0.20 0.02 to 0.37 .031 9 45
Cancer present 5 612 10.1 4 .039 60.3 0.16 20.11 to 0.43 .235 — —
Disease free 13 1,432 15.1 12 .235 20.1 0.33 0.20 to 0.45 , .001 107 75
Study design: RCT 16 1,769 27.8 16 .034 42.4 0.29 0.15 to 0.43 , .001 100 90
Study design: CT 2 413 0.8 1 .386 0.0 0.43 0.22 to 0.64 , .001 — —
Format: individual 8 1,121 6.7 7 .463 0.0 0.19 0.07 to 0.31 .002 17 50
Format: group 10 923 15.8 9 .072 42.9 0.36 0.18 to 0.55 , .001 59 60
Delivery: face to face 14 1,417 25.8 13 .018 49.7 0.31 0.15 to 0.47 , .001 96 80
Delivery: other 4 627 0.4 3 .933 0.0 0.23 0.07 to 0.38 .006 4 30
FCR as primary target 8 1,135 14.0 7 .051 50.1 0.36 0.19 to 0.54 , .001 68 50
FCR as secondary target 10 910 9,6 9 .387 5.9 0.19 0.01to 0.33 .009 11 60
FCR level as inclusion criterion 2 362 0.4 1 .505 0.0 0.43 0.24 to 0.62 , .001 — —
FCR level not inclusion criterion 16 1,683 23.3 15 .079 35.5 0.26 0.12 to 0.39 , .001 88 90
Therapy: traditional CBT 7 1,025 11.1 6 .086 45.8 0.22 0.04 to 0.40 .015 17 45
Therapy: contemporary CBT 8 744 2.6 7 .902 0.0 0.30 0.16 to 0.45 , .001 20 50

TABLE 2. Pooled Postintervention and Follow-Up Effects of Psychological Interventions on Fear of Cancer Recurrence Among Survivors of
Cancer (continued)
Sample
Size Heterogeneity* Global Effect Size
Effect K No. Q df P I2 Hedges’s g† 95% CI P Failsafe No.‡ Criterion§

Therapy: other 3 276 11.4 2 .003 82.4 0.54 20.08 to 1.16 .088 — —
FCR measure: CARS 7 1,086 19.7 6 .003 69.5 0.34 0.10 to 0.57 .005 35 45
FCR measure: FCRI 4 382 1.1 3 .775 0.0 0.22 0.02 to 0.42 .031 0 30
Abbreviations: CARS, Concerns About Recurrence Scale; CBT, cognitive behavioral therapy; CT, controlled trial; FCR, fear of cancer
recurrence; FCRI, Fear of Cancer Recurrence Inventory; RCT, randomized controlled trial.
*Q-statistic: P values , .1 are taken to suggest heterogeneity. I2 statistic: 0% (no heterogeneity), 25% (low heterogeneity), 50% (moderate
heterogeneity), and 75% (high heterogeneity).
†Effect size: Hedges’s g. A positive value indicates an effect size in the hypothesized direction. All effect sizes were combined using a random
effects model. Conventions: small (0.2), medium (0.5), or large (0.8).27
‡Number of nonsignificant studies that would bring the P value to nonsignificant (P . .05).
§A failsafe number that exceeds the criterion (5 3 K + 10) indicates a robust result.37
kK , 23, as two studies did not assess outcomes at postintervention.
found no statistically significant effect (g = 0.15; P = .44; no shorter time to follow-up (in weeks; b = 2.01; P = .027) and
additional data shown).70 with group-based format compared with individual treat-
ment format (b = .18; P = .041; Data Supplement).
Main Effects Changes in raw scores for the two most frequently used
Results of the meta-analyses are listed in Table 2 and il- FCR measures—Concerns About Recurrence Scale and
lustrated with forest plots in Figure 2 and the Data Sup- Fear of Cancer Recurrence Inventory—corresponded to
plement. The overall combined postintervention ES was mean differences of 1.3 (95% CI, 0.4 to 2.3; Concerns
statistically significant and of small magnitude (g = 0.33; About Recurrence Scale overall fear) and 2.2 (95% CI,
95% CI, 0.20 to 0.46; P , .001). There were no indications 1.4 to 3.1; Fear of Cancer Recurrence Inventory severity
of publication bias, and the failsafe number for effects at subscale; Data Supplement).
post-treatment (failsafe n = 255) exceeded the criterion
(n = 115), which suggested a robust result. The overall Risk of Bias
combined effect at follow-up was statistically significant and Before negotiation, the two raters (L.S. and G.O.) agreed
only slightly smaller than at postintervention (g = 0.28; P , on 150 (81.5%) of 184 risk of bias ratings, and the inter-
.001). Again, there were no indications of publication bias, rater agreement (k39) for the individual domains ranged
and follow-up results seemed to be robust. from almost perfect (0.91; random sequence allocation)
to fair (0.39; treatment integrity). Final negotiated results
Heterogeneity of risk of bias assessments for each study are shown in
Statistically significant Q tests and moderate I2 values for Figure 3 (for additional details, see the Data Supplement).
both postintervention (48.6%) and follow-up results (36.6%; No associations were found between total risk of bias
Table 2) suggested some degree of variability in ESs scores and ESs at postintervention and follow-up
beyond sampling error. (Table 3).
Subgroup and Moderation Analyses Overall Quality of Meta-Analytic Evidence

As shown in Table 2, when examining the results of the The overall evidence for RCTs was qualified using
prespecified study subgroups—categorized according to GRADE.41 Overall, moderate quality of evidence demon-
cancer type, disease status, study design, format, delivery, strates that psychological intervention may reduce FCR
FCR as primary or secondary target, FCR level as inclusion symptom compared with control conditions. The level of
criterion or not, and psychotherapeutic framework—ESs evidence for RCTs was downgraded to moderate as a result
were, with few exceptions, generally comparable across of concerns regarding inconsistency—that is, methodo-
subgroups of studies. Almost all ESs were of small mag- logic and clinical heterogeneity and inability to identify the
nitude at both postintervention and follow-up. Results of the reasons for heterogeneity—and indirectness—that is, that
meta-regression analyses are listed in Table 3. At post- a considerable proportion of studies (K = 13) had FCR as
intervention, effects of contemporary CBTs (g = 0.42) were secondary outcome, most studies included women only,
larger than those of traditional CBTs (g = 0.24; b = .22; P = and the majority of studies focused on FCR in cancer
.018). At follow-up, larger effects were associated with survivors, not fear of progression in patients with cancer

Tauber et al
Study ES (95% CI) Weight (%)*
Sterba et al (2015) -0.22 (-0.65 to 0.20) 4.93

Shields et al (2010) -0.13 (-1.11 to 0.85) 1.44
Merckaert et al (2016) 0.04 (-0.27 to 0.35) 6.65
Herschbach et al (2010) 0.06 (-0.15 to 0.27) 8.48
Manne et al (2017) 0.11 (-0.14 to 0.37) 7.64
Victorson et al (2017) 0.15 (-0.48 to 0.77) 2.97
Gonzalez-Hernandez (2018) 0.16 (-0.39 to 0.71) 3.57
Dieng et al (2016) 0.21 (-0.12 to 0.53) 6.34
Lichtenthal et al (2017) 0.26 (-0.16 to 0.68) 5.00
Dodds et al (2015) 0.27 (-0.46 to 1.00) 2.35
Bower et al (2015) 0.31 (-0.16 to 0.77) 4.43
Lengacher et al (2016) 0.33 (0.10 to 0.56) 8.17
Humphris and Rogers (2012) 0.49 (0.05 to 0.92) 4.82
van de Wal et al (2017) 0.54 (0.12 to 0.97) 4.96
Butow et al (2017) 0.57 (0.26 to 0.88) 6.69
Heinrichs et al (2012) 0.57 (0.10 to 1.04) 4.41
Crane-Okada et al (2012) 0.57 (-0.06 to 1.20) 2.96
Lengacher et al (2009) 0.60 (0.14 to 1.06) 4.53
Tomei et al (2018) 0.72 (-0.16 to 1.60) 1.73
Cameron et al (2007) 0.73 (0.26 to 1.21) 4.33
Bannaasan et al (2015) 1.13 (0.59 to 1.68) 3.63
Overall (I2 = 48.6%; P = .007) 0.33 (0.20 to 0.46) 100.00
-1.2 0 1.8
Increases FCR Decreases FCR
FIG 2. Forest plot of effect sizes (ESs; Hedges’s g) for effects at postintervention of psychological interventions on fear of cancer recurrence (FCR).
(*) Weights are from random effects analysis.
present. Overall, no serious concerns were found for risk of individual at risk of depression, impaired daily functioning,
bias, imprecision, and publication bias. using unnecessary health assessments, and reduced
quality of life.1,2 Furthermore, current findings point to
lasting effects of FCR interventions beyond the immediate
DISCUSSION
completion of the intervention. This finding is particularly
The primary objective of the current study was to evaluate relevant, as unmanaged FCR tends to stabilize over time.2,7
the efficacy of psychological interventions in alleviating FCR Here, it should be noted that follow-up times varied from
symptoms among patients with and survivors of cancer. 6 weeks to 78 weeks across studies and that meta-
Twenty-three controlled studies were identified, revealing regression demonstrated that longer time to follow-up as-
a statistically significant effect on FCR outcomes of a small sessment was associated with a statistically significantly
magnitude (g = 0.33) immediately after intervention, which
smaller effect. Number of sessions ranged from one to 15,
was largely maintained at follow-up (g = 0.28), on average
with an average of 6.6 sessions, but no associations were
more than 7 months after the intervention. Results were
found between the number of sessions and ES either at
robust with no indications of publication bias, which sup-
postintervention or at follow-up.
ported our hypothesis that psychological interventions
would be efficacious relative to controls in reducing FCR A secondary aim was to explore the possible influence
symptoms. These findings are encouraging, given that of between-study differences. The larger effect found at
managing FCR is a common unmet need among survivors postintervention for contemporary CBTs (g = 0.42) com-
of cancer6 and, when persistent and excessive, leaves the pared with traditional CBTs (g = 0.24) supports a hypothesis

TABLE 3. Moderators of Effects at Postintervention and Follow-Up: Results of Meta-Regression Analyses

Moderator K b* 95% CI P (two tailed)
Postintervention
Cancer type: breast (referent: other) 21 0.01 20.24 to 0.25 .969
FCR primary target (referent: secondary) 21 0.15 20.10 to 0.39 .255
FCR level inclusion criterion (referent: not a criterion) 21 0.04 20.25 to 0.33 .788
Format: group (referent: individual) 21 0.09 20.16 to 0.34 .477
Delivery: face to face (referent: other) 21 0.28 20.05 to 0.60 .094
Therapy: contemporary CBT (referent: traditional CBT) 18 0.22 0.04 to 0.41 .018
Gender: percent women in sample (range, 0% to 100%) 21 0.00 20.01 to 0.01 .882
Time to postintervention assessment, weeks (range, 2-26) 21 20.01 20.03 to 0.01 .327
No. of sessions (range, 1-15) 21 0.01 20.03 to 0.04 .673
Mean sample age, years (range, 44-70) 21 0.00 20.03 to 0.03 .911
Risk of bias score (range, 1-13) 21 20.01 20.04 to 0.04 .984
FCR measure: CARS (referent: FCRI) 13 0.04 20.25 to 0.34 .766
Follow-up
Cancer type: breast (referent: other) 18 0.15 20.06 to 0.37 .162
FCR primary target (referent: secondary) 18 0.16 20.04 to 0.36 .115
FCR level inclusion criterion (referent: not a criterion) 18 0.18 20.05 to 0.42 .124
Format: group (referent: individual) 18 0.18 0.01 to 0.36 .041
Delivery: face to face (referent: other) 18 20.07 20.31 to 0.17 .551
Therapy: contemporary CBT (referent traditional CBT) 15 0.07 20.13 to 0.28 .486
Gender: percent women in sample (range, 0% to 100%) 18 0.00 20.01 to 0.01 .377
Time to follow-up assessment, weeks (range, 6-78) 14 20.01 20.01 to 20.00 .027
No. of sessions (range, 1-12) 17 20.02 20.07 to 0.03 .435
Mean sample age, years (range, 44-70) 18 20.01 20.03 to 0.01 .522
Risk of bias score (range, 1-13) 18 0.02 20.01 to 0.06 .130
FCR measure: CARS (referent: FCRI) 11 0.10 20.23 to 0.43 .566
Abbreviations: CARS, Concerns About Recurrence Scale; CBT, cognitive behavioral therapy; FCR, fear of cancer recurrence; FCRI, Fear of
Cancer Recurrence Inventory.
*Maximum likelihood method.
that FCR may be particularly responsive to contemporary the presence of cancer, nor age was associated with overall
therapies that aim to change the way in which individuals intervention effect. Given the relatively small number of
relate to their inner experiences by focusing on cognitive studies in the moderation analyses, which likely compro-
processing and metacognitions in FCR—for example, mised our statistical power, two results should be noted
worry, rumination, or attentional bias.78,79 The difference no when considering the numerical difference in ESs. First, the
longer reached statistical significance at follow-up, mainly ES obtained at post-treatment with treatment delivered face
because of smaller ESs of contemporary CBTs at follow-up, to face was numerically larger (g = 0.38) than treatments
which perhaps suggests that meta-cognitive skills learned that were delivered by other means (eg, telephone or Web
in contemporary CBTs require booster sessions or materials based; g = 0.10). Only three studies used such other
to maintain long-term effects. Larger effects at follow-up delivery means and results should be interpreted accord-
were associated with shorter time to follow-up and with ingly; the small number of studies demonstrated that
delivery methods other than traditional face-to-face treat-
a group-based format compared with an individual treat-
ments are largely unexplored within the context of FCR.
ment format. We have no clear explanation for the latter
Internet-based interventions have previously been shown to
finding, which could be explored in future research.
be effective for anxiety disorders and fear-related condi-
All remaining moderation analyses failed to reach statistical tions80 and have obtained equivalent effects to face-to-face
significance. It has previously been found that newly di- treatments.81 It remains a question of whether this could be
agnosed patients with cancer and younger survivors are the case for FCR as well. Second, studies with FCR as their
more prone to experiencing high levels of FCR,2 but neither primary target obtained larger ESs at both postintervention

Tauber et al
Random sequence generation - ? - ? + + + + + ? ? + ? + ? + + + + ? + + +

Allocation concealment - ? - ? + ? + + ? ? ? + ? ? ? + + + ? ? + + +
Blinding of outcome assessment - ? ? ? - ? + ? ? ? ? ? ? ? ? ? ? ? + ? + + ?
Accounting for attrition - + - + - + + + ? + + + + + + + + + - + + - +
Selective reporting ? - ? ? ? ? ? + ? ? ? ? ? - ? - - + ? ? + + +
Treatment integrity ? + ? ? + ? ? + + - ? ? N/A ? N/A + N/A + ? + + + +
Conflict of interest ? ? ? ? - ? ? - ? ? ? + + - ? ? + + ? + - + +
Bias in sampling and dropout - + - + ? - ? + ? + + ? + + + + ? + + ? + ? + FIG 3. Risk of bias. Blue box with
plus sign indicates a low risk of bias;
Cameron et al, 2007
Lengacher et al, 2009
Herschbach et al, 2010
Shields et al, 2010
Heinrichs et al, 2012
Crane-Okada et al, 2012
Dieng et al, 2012

Germino et al, 2013
Bannaasan et al, 2015
Bower at al, 2015
Dodds et al, 2015
Sterba et al, 2015
Lengacher et al, 2016
Otto et al, 2016
Merckaert et al, 2017
Lichtenthal et al, 2017
van de Wal et al, 2017
Victorson et al, 2017
Manne et al, 2017
Butow et al, 2017
Gonzalez-Hernandez et al, 2018
Tomei et al, 2018
Humphris and Rogers, 2012
red box with question mark indicates
an unclear risk of bias; teal box with
minus sign indicates a high risk of
bias. N/A, not applicable.
and follow-up (g = 0.42; 0.36) than studies examining abandoning certain treatment components or increasing or
FCR as a secondary target (g = 0.26; 0.19). This finding decreasing the dose. Theoretical formulations of FCR78
should be further explored as the number of treatment could guide researchers in identifying relevant markers to
studies increases, sufficiently powering analyses to test investigate.
whether treatments with FCR as their primary target are
Our results should be viewed in light of limitations that
superior in reducing FCR symptoms compared with
pertain to the methodology of the included studies and
generalized interventions. In addition, only four studies
between-study heterogeneity, noting that overall strength of
included participants on the basis of their FCR symptom
the evidence was downgraded to moderate. Many studies
levels and it is unclear to what degree this may have
suffered from the risk of selective reporting. Although
influenced results.
evaluating the effect within the different categories pertaining
Robust but relatively small effects point to a number of to each of the identified moderators, between-study het-
potential implications, both clinically and for future research. erogeneity for most categories remained moderate to large.
Establishing the efficacy of psychological interventions for This could indicate potentially unidentified variables that are
FCR should also concern which treatment components may responsible for systematic variation. Finally, it should be
be most efficacious or which processes drive the effect. noted that all but four authors have contributed to the
Fardell et al78 have suggested a number of key maintaining studies included in the present review, which might raise
processes of FCR, resulting in a theoretical model with concerns regarding bias. However, this may be less of an
dysfunctional cognitive processes at its core. The authors issue as the review was preregistered; all authors agreed to
suggest that particular treatment components from con- the final protocol; the first, second, and corresponding
temporary CBTs, including metacognitive therapy82 and authors (N.M.T., M.S.O., and R.Z.) have not yet published
acceptance and commitment therapy,83 are well suited for any intervention studies on FCR; and screening and data
targeting such processes. Future treatment trials should not extraction was performed by authors who had not been
only establish the efficacy of their treatment, but also in- principle investigators of any of the reviewed studies.
vestigate which components are most change potent. One
approach could be the Multiphase Optimization Strategy,84 In conclusion, to our knowledge, this is currently the most
a systematic method for exploring the main and interactive comprehensive systematic review and meta-analysis of the
effects of treatment components and investigating select effect of controlled psychological intervention studies
treatment components in a factorial design where all pos- specifically on FCR outcomes. Twenty-three CTs were lo-
sible combinations of components are evaluated. Further- cated, revealing a statistically significant effect on FCR
more, the dose needed for effective treatment of FCR is likely outcomes of a small magnitude that was largely maintained
not identical for all individuals and intervention researchers at follow-up. Psychological interventions therefore seem to
are increasingly interested in ways to individually tailor be efficacious in reducing FCR symptoms. Future trials
psychotherapy (eg, Fisher and Boswell).85 Existing therapies should focus on targeted interventions for FCR, include
already suggest conducting a thorough individual case participants on the basis of high levels of FCR, and in-
formulation58; however, to date, treatment programs for FCR vestigate how to further optimize interventions—for in-
have not outlined or investigated markers—for example, time stance, by exploring the effect of different treatment
since diagnosis, severity of FCR, or level or type of dys- components and tailoring the intervention to the in-
functional cognitive processes—suggestive of including or dividual’s FCR symptoms.

AFFILIATIONS SUPPORT
1
Aarhus University, Aarhus, Denmark Supported in part by Danish Cancer Society Grant No. R150-A10080.
2
International Psycho-Oncology Society Fear of Cancer Recurrence
Special Interest Group, Toronto, Ontario, Canada AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
3
Technical University of Munich, Munich, Germany AND DATA AVAILABILITY STATEMENT
4
Queen’s University, Kingston, Ontario, Canada Disclosures provided by the authors and data availability statement (if
5
University of St Andrews, St Andrews, United Kingdom applicable) are available with this article at DOI https://doi.org/10.1200/
6
University of Ottawa, Ottawa, Ontario, Canada JCO.19.00572.
7
McGill University, Montréal, Québec, Canada
8
Radboud University Medical Centre, Nijmegen, the Netherlands
9 AUTHOR CONTRIBUTIONS
University of Sydney, Sydney, NSW, Australia
10
Ingham Institute for Applied Medical Research and University of New Conception and design: Nina M. Tauber, Mia S. O’Toole, Andreas Dinkel,
South Wales, Sydney, NSW, Australia Sophie Lebel, Christine Maheu, Gozde Ozakinci, Judith Prins, Louise
11
Université du Québec à Chicoutimi, Saguenay, Québec, Canada Sharpe, Allan “Ben” Smith, Belinda Thewes, Sébastien Simard, Robert
12
Aarhus University Hospital, Aarhus, Denmark Zachariae
Administrative support: Nina M. Tauber
Provision of study materials or patients: Judith Prins
CORRESPONDING AUTHOR
Collection and assembly of data: Nina M. Tauber, Jacqueline Galica,
Robert Zachariae, DMSc, Aarhus University Hospital, Bartholin’s Allé 9,
Christine Maheu, Judith Prins, Louise Sharpe, Allan “Ben” Smith,
Blvd 1350, 8000 Aarhus C, Denmark; e-mail: [email protected].
Belinda Thewes, Sébastien Simard, Robert Zachariae
Data analysis and interpretation: Nina M. Tauber, Mia S. O’Toole, Andreas
PRIOR PRESENTATION Dinkel, Gerry Humphris, Sophie Lebel, Christine Maheu, Gozde Ozakinci,
Presented at the 20th World Congress of Psycho-Oncology, Hong Kong, Judith Prins, Belinda Thewes, Sébastien Simard, Robert Zachariae
Special Administrative Region, People’s Republic of China, October 29- Manuscript writing: All authors
November 2, 2018. Final approval of manuscript: All authors
Accountable for all aspects of the work: All authors
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n n n

Tauber et al
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Effect of Psychological Intervention on Fear of Cancer Recurrence: A Systematic Review and Meta-Analysis
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held
unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about
ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc.
Andreas Dinkel Robert Zachariae

Honoraria: Novartis Pharma Stock and Other Ownership Interests: Novo Nordisk
Honoraria: Pfizer, Sanofi
Allan “Ben” Smith
Research Funding: Boehringer Ingelheim (Inst)
Research Funding: AstraZeneca (Inst), Pfizer (Inst)
Belinda Thewes No other potential conflicts of interest were reported.
Employment: The Health Psychology Clinic
© 2019 by American Society of Clinical Oncology Volume 37, Issue 31


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Effect of Psychological Intervention on Fear of

INTRODUCTION FCR is among the most commonly reported concerns

Volume 37, Issue 31 2899

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Records screened after

Full-text articles assessed Records excluded (n = 71)

Independent studies included Studies excluded from

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Journal of Clinical Oncology

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2904 © 2019 by American Society of Clinical Oncology

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Volume 37, Issue 31

Journal of Clinical Oncology

Stage 1-4 100% female 9 (79) (352, 352)

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2906 © 2019 by American Society of Clinical Oncology

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Volume 37, Issue 31

Journal of Clinical Oncology

Stage 1-3 N/A (1) (12)

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Effect K No. Q df P I2 Hedges’s g† 95% CI P Failsafe No.‡ Criterion§

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Effect K No. Q df P I2 Hedges’s g† 95% CI P Failsafe No.‡ Criterion§

Subgroup and Moderation Analyses Overall Quality of Meta-Analytic Evidence

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Study ES (95% CI) Weight (%)*

Sterba et al (2015) -0.22 (-0.65 to 0.20) 4.93

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TABLE 3. Moderators of Effects at Postintervention and Follow-Up: Results of Meta-Regression Analyses

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Random sequence generation - ? - ? + + + + + ? ? + ? + ? + + + + ? + + +

Dieng et al, 2012

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AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Andreas Dinkel Robert Zachariae

© 2019 by American Society of Clinical Oncology Volume 37, Issue 31

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