The Feasibility and Acceptability of a Psychosocial Intervention for Advanced Colorectal Cancer Patients

Cancer is the leading cause of death in Singapore and colorectal cancer is the most frequently diagnosed cancer in males and second most frequently diagnosed cancer in females, accounting for 17% and 13% of all cancers respectively. Such high incidence rates are consistent with reports of colorectal cancer being a disease of ageing and developed nations . A total of 8931 new cases of colorectal cancer were diagnosed in Singapore from 2009 and 2013, with data indicating a steep increase in incidence rate for patients aged 50 and above. Given that the number of adults aged 65 years and older to double from 2009 to 2030 (Singapore Department of Statistics), the number of colorectal cancer cases are also expected to increase.

Advanced colorectal cancer refers to stage IV cancer of the colon or rectum that cannot be cured and has metastasized to at least one distant organ or set of lymph nodes, and that will likely continue to spread, leading to end of life (National Cancer Institute). In Singapore between 2009 and 2013, approximately 25% of colorectal cancer cases were at stage IV. According to the U.S. NCI's SEER database of patients from 2004-2010, 5-year survival rates for stage IV colon and rectal cancer were 11% and 12% respectively, suggesting these patients are or will soon be managing symptoms of their disease like pain while psychologically confronting end-of-life.

The news of metastatic disease, treatment failure, and/or bleak prognosis can be demoralizing for some patients and characterized by shock, denial, anger, anxiety, and depression which can interfere with everyday living. Studies have reported about one-third to half of advanced cancer patients experience psychological distress and existential crises, yet studies indicate the needs of these patients are not properly assessed and addressed as healthcare providers tend to focus more on patients' physical problems and do not have the time and perceived competency to address emotional distress.

Colorectal cancer comes with its own set of challenges that can significantly alter patients' daily living and affect patient psychological well-being and quality of life. Bowel-related issues have been reported to present physical, psychological, and social challenges to patients and survivors. For instance, patients with surgically-created stoma as part of treatment may face complications of leakage, skin, and odour issues that can lead to anxiety, disturbance in body image, low self-esteem, and social isolation. Furthermore, clinical anecdotes have pointed toward this patient population being concerned about lifestyle factors influencing their disease progression, especially diet. Psychological care has been increasingly recognized as an important part of treatment for this population at such a vulnerable time. Psychological care aims to address patients' mood and worries as they deal with their illness and to help patients find a sense of meaning in their life despite their cancer-related suffering. Unfortunately, psychological care as part of oncology supportive/ palliative services is still very rudimentary in Singapore.

Cognitive behavioural therapy is a widely used, evidence-based therapy that focuses on cognitions, emotions, and behaviour change to address patient distress. This framework has been successfully applied in the treatment of many disorders, including anxiety disorders, depression, chronic pain, and insomnia. It is posited that psycho-behavioural interventions (PBIs) that are based on cognitive-behavioural frameworks can be designed to meet the needs of cancer patients by targeting and modifying their maladaptive thoughts about the disease and treatment (e.g., irrational beliefs, negative attitudes, unrealistic expectations) and their behaviour (e.g., maladaptive coping strategies, isolation, self-negligence). This can be done by teaching patients strategies such as cognitive restructuring, meaning-making, relaxation, activity-pacing, effective communication with others, and utilization of social support. By learning these skills, patients are expected to have increased health-related self-efficacy (i.e., belief in the capacity to manage one's health) that may act as a buffer from them prematurely adopting the "sick role". Self-efficacy can be extremely important in the context of advanced cancer as it allows patients to feel more in control of a situation that is often distressing because of the uncertainty associated with the illness. This in turn may have an effect on patient psychological well-being, symptom management, and utilization of healthcare services such as emergency department (ED) visits and inpatient hospitalizations.