The Engagement of Cancer Patients and Survivors in Individual Psychological Treatment

Abstract

Distress, including anxiety, depression and fear of cancer recurrence, is prevalent amongst cancer patients. Recent meta-analyses report that psychological interventions are efficacious in the treatment of existing distress in this population. Efforts to ensure that cancer patients are assessed for distress and offered appropriate psychological support have increased over recent years. However, according to existing research from survey studies, interest in engaging with psychological support is low. Little is known about the reasons for cancer patients’ engagement and non-engagement with psychological care. Several studies were conducted in order to learn more about what differentiates patients who accept versus decline, or adhere to psychological treatment versus drop out, and what clinicians might do in order to facilitate greater engagement in those with unmet need. Factors affecting engagement with individual psychological therapy was the focus. In Study 1, existing literature reporting patient variables such as gender, age, stage or type of cancer, and level of distress, and the association between these variables and interest in psychological therapy was systematically reviewed. Comparisons between those interested in psychological care and those declining, and/or those adhering versus dropping out of treatment from 26 studies were examined. No clear relationships were demonstrated between socio-demographic variables including gender, age and relationship status, or cancer stage or site, and uptake or adherence to psychological intervention across studies. Study 2 similarly examined existing literature, with two aims: firstly, to meta-analytically determine rates of uptake of and adherence to psychological therapy, and secondly, to identify, using meta-regression technique, which characteristics of interventions are associated with greater uptake and adherence. Data from 53 studies reporting uptake and/or adherence rates were included in analyses. The weighted uptake and adherence rates were 60.1% and 90.4%, respectively. Surprisingly, patients screened and identified as distressed were less likely to accept intervention than unselected patients. Uptake was higher for interventions delivered by telephone rather than face-to-faceand when intervention was offered prior to medical treatment compared to later. Interventions delivered by nurses were associated with a higher rate of uptake than interventions delivered by psychologists, social workers or psychiatrists. In Study 3, semi-structured interviews were conducted with 24 early stage breast or colorectal cancer survivors. Interviewees had either accepted or declined psychological care during the course of medical treatment or when offered participation in a trial of an intervention to reduce fear of cancer recurrence after medical treatment was completed. Reasons for decline included a desire to contain and not explore feelings, belief that distress levels were not severe enough to warrant intervention, and feeling well supported by family and friends. Learning specific techniques and strategies to cope with cancer or worries about cancer, and having someone to talk to openly about cancer were seen as reasons to accept psychological treatment. Survivors suggested that psychological treatment should ideally be offered close to diagnosis or at the end of treatment, and suggested nurses as ideal to raise the idea with patients. In Study 4, an expert panel participated in a three-round web-based “Delphi” survey, answering questions about perceived barriers to and facilitators of acceptance of psychological care and ultimately developing a consensus based list of 24 strategies for engaging distressed cancer patients into psychological care when a need is indicated. The panel consisted of twenty-two experienced psycho-oncology professionals; psychologists, social workers, nurses and psychiatrists. Barriers proposed by panellists included stigma, patient desire to focus on resilience, doubt that intervention would help and lack of knowledge about what constitutes psychological care. Engagement strategies that were highly endorsed included those that normalised need for psychological care, and the integration of the presentation of psychological care as a typical part of cancer care. Conclusions Importantly, these findings indicate that only 50% of cancer patients who have been screened and identified as distressed accept offers of psychological intervention. A potentially important reason for non- interest in psychological care amongst those who are distressed is the desire to contain emotions and avoid examination of distress. Many of the findings presented are of immediate clinical utility: several characteristics of interventions have been identified as being associated with greater interest in psychological therapy, and a list of 24 strategies for engagement has been generated by an expert panel of psycho-oncology professionals.