Toward implementation of an evidence‐based intervention for fear of cancer recurrence: Feasibility in real‐world psycho‐oncology practice

Few evidence‐based interventions addressing high levels of fear of cancer recurrence (FCR) have been implemented. Understanding how these might be implemented is crucial to bridge the research‐practice gap. This study investigated the feasibility of implementing the blended Survivors' Worries of Recurrent Disease (SWORD) intervention in real‐world psycho‐oncology practice.


| Design
During a 15-month period from February 2021 to May 2022, (during the COVID-19 pandemic and associated restrictions), an assessment of clinical FCR and treatment with SWORD were offered as part of standard care in a university hospital, a regional hospital, and a psycho-oncology center (POC).A description of the standard care for clinical FCR in the three participating centers has been published before. 14The current study comprised a mixed method design, including registration of demand for SWORD, a single arm pre-post questionnaire study in patients, interviews with patients, a focus group with psychologists, and field notes.

| Intervention
The original SWORD intervention comprises eight sessions with a psychologist accompanied by an interactive eHealth platform of psychological education and home exercises.The principal therapeutic techniques are self-monitoring, cognitive restructuring, and exposure and response prevention.Other techniques are psychoeducation, relaxation, mindfulness, reframing, modeling, goal planning, and attainment. 11Before offering SWORD as part of care for clinical FCR, minor adaptations were made (Box 1).These were guided by a model for adaptation of evidence based health interventions, ADAPT-ITT, 16 and informed by an interview study with patients and HCPs. 14Fidelity to the core treatment components was maximized while increasing its feasibility. 17The adapted treatment indication for SWORD was based on recent criteria for clinical FCR, 6,18 and included need for help and treatment motivation (Box 2).This is different from the original treatment indication, which was based on the Cancer Worry Scale (CWS-6) score only. 12ucational tools for SWORD were developed including new therapist training addressing the assessment of eligibility for SWORD, the content of the intervention, and working with eHealth.
We also designed questions for psychologists to guide their clinical assessment for FCR. 18Psychologists were encouraged to discuss the intervention in multidisciplinary meetings in order to promote referrals and an education video was developed for referrers to recognize high levels of FCR.

| Participants
All patients eligible for and accepting SWORD were asked to participate in the questionnaire study.Informed deviations from the treatment indication were allowed and documented in order to 2 of 14 -DEUNING-SMIT ET AL. assess actual use.Participating psychologists were registered healthcare and clinical psychologists with experience in this field.In the university hospital and POC all psychologists working with psycho-oncology patients were involved.In the general hospitals, a selection of psychologists participated.The number of psychologists per center differed during the study due to staff turnover.Psychologists received supervision from a clinical health psychologist experienced in SWORD.

| Procedure
Psychologists assessed patients' eligibility for SWORD during the standard psycho-oncology intake.Eligible patients were informed about SWORD.Patients accepting SWORD were informed about the questionnaire study.Those refusing study participation received SWORD as part of usual care.Participants providing informed consent for the study received a questionnaire (web-based or paperand-pencil) prior to the first session (T0) and after completion of session 8 (T1).Patients who did not complete SWORD still received T1 questionnaires following treatment drop-out.Here patients could opt to participate in a semi-structured phone interview.Interview participants were purposefully selected based on: center, sex, tumor type, and self-reported effect of treatment.Recruitment was ended when the variation in patients' characteristics was achieved and the domains limited effectiveness, degree of execution, acceptability, practicality, and integration, were sufficiently addressed according to the Bowen framework.
All nine actively engaged psychologists at study close-off were later invited to share their experience in an online focus group.Two researchers (ED, JC) guided the focus group.

| Deviations from the study protocol
In general SWORD has only been delivered by registered health and clinical psychologists.However, this appeared difficult in the POC due to their capacity and finances.Therefore, this study accepted regular POC procedures allowing both registered and non-registered psychologists to deliver SWORD.The latter, who do have a master's degree in psychology, were supervised by registered psychologists.
SWORD and the questionnaire study was paused twice in the POC due problems with reimbursements related to our study (4 weeks)   and the switch in psychologists delivering SWORD (6 weeks).
Registering demand for SWORD was not paused during these weeks.

| Measures
Firstly (T0), we assessed demographic characteristics, including age, sex, education, and medical characteristics, including diagnosis, treatment, and history of psychological help.

| Demand
We investigated the demand for SWORD.Psychologists anonymously registered the number of oncology patients referred to the psycho-oncology service.From this registry we derived the following outcomes: eligibility, that is the number of patients eligible for SWORD divided by the number of patients referred; uptake, that is the number of patients receiving SWORD divided by the number of patients offered SWORD; completion rate, that is the number of patients completing SWORD divided by the number of patients who started with SWORD and; patients willingness to participate in the evaluation study.

| Limited effectiveness
We investigated whether SWORD was effective in an actual clinical setting.We used the CWS-6 (T0-T1) as primary effectiveness measure with total scores ranging from 6 to 24.Higher scores indicated a higher FCR.The CWS-6 is reliable (Cronbach's α = 0.78) with a cutoff score of CWS-6 ≥ 12 validated to differentiate normal FCR from higher levels. 19Secondary effectiveness measures used were: the FCR severity measured by the Fear of Cancer Recurrence Inventory Short Form (FCRI-SF; T0-T1) 20 ; the Health related quality of life (HR-QoL) measured by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC-C30; T0-T1) 21 ]; and the expectation of changes in anxiety measured by the Anxiety Change Expectancy Scale (ACES; T0-T1). 22,23 addition, five purpose designed questions were used to assess self-reported effectiveness (T1).A guide was designed for patient interviews with questions about FCR reduction, acquired skills, and how the intervention affected daily life.A topic guide was designed for the online focus group with questions about the effectiveness of SWORD.

| Degree of execution
We investigated whether SWORD was carried out as intended.
We assessed the treatment dose patients received, and fidelity to the treatment manual.Psychologists completed a checklist after each session with closed questions about adherence to SWORD, and an open question to document reasons for deviation.This information was supplemented both by patient interviews asking, for example, how they completed their homework, and focus group data on, for example, the reasons psychologists gave for deviation.

| Acceptability
Here we investigated whether SWORD was judged as suitable, satisfying, and attractive to deliverers and recipients.A patient evaluation questionnaire (T1) adapted from previous studies 24,25 assessed satisfaction and an evaluation of both the treatment content and eHealth platform.The System Usability Scale (SUS; T1) assessed how easy it was to use the eHealth platform.The TWente Engagement with eHealth Technologies Scale (TWEETS; T1) measured cognitive, effective, and behavioral engagement with eHealth technology. 26Patient interviews and the focus group included questions about satisfaction with SWORD.

| Practicality
We looked at whether SWORD could be carried out by psychologists with the skills and knowledge which already exist.Patient interviews included questions about the psychologists and the centers.In the focus group, psychologists were asked about their ability to deliver SWORD and the use of the tools provided, such as for training, supervision, the CWS-6, and guidance questions.We collected researcher (ED)'s field notes in a study logbook.This included observations made during meetings, phone calls, and email contact with psychologists and managers from the centers together with the field notes of the psychologist supervising.

| Integration
We looked at whether SWORD could be integrated within existing infrastructure.Patient interviews included questions about the referral, intake, and treatment.The focus group included questions about how SWORD fitted into the existing infrastructure and organization of care.We also asked about expected and perceived barriers and facilitators for the sustainability of SWORD in their routine care.Field notes supplemented the data.

| Data analysis
We analyzed, using descriptive statistics: the intake registration forms, the session checklists, the SUS and TWEETS, and the purpose designed evaluation questionnaire.

| Statistical effectiveness
This was tested through repeated measures ANOVA with CWS-6, FCRI, HRQOL and ACES at T0 and T1 (partial eta squared (ηp 2 ) > 0.01 small, ηp 2 > 0.06 medium, ηp 2 > 0.14 large effect size 27 ).We also looked at Cohen's d z (>0.2 small, >0.5 medium, >0.8 large effect size).The missing T1 scores on the CWS-6 were imputed for sensitivity analyses, by using last observation carried forward (LOCF) -a conservative approach.Differences in effectiveness between centers and between registered psychologists and non-registered psychologists were evaluated with mixed ANOVA.A dose-response relationship was calculated.Statistically significant change in the CWS-6 was analyzed with the reliable change index (RCI), with RCI < −1.96 indicating reliable improvement.Clinically significant change was defined as CWS-6 < 12 at T1.An individual was considered to have clinically significant improvement when both criteria were met (RCI < −1.96 and CWS-6 < 12).

| Qualitative data
Audio of the focus group and patient interviews were transcribed verbatim.All qualitative data were charted according to the feasibility outcomes, were summarized, and then integrated with the other data.

| Description of the study sample
The demographic and medical characteristics of the study participants (n = 59) are displayed in Table 1.Participants were predominantly female (86%) with a mean time since diagnosis of 2.7 years and time since treatment of 1.8 years.The time since diagnosis and treatment were lowest in the university hospital and highest in the POC.The majority had psychological help before.Half of the participants was diagnosed with breast cancer.Two patients with an ongoing hematologic cancer diagnosis were included.This was an informed deviation from the treatment indication based on psychologists' clinical judgment.The majority completed T1 (49/59; 83%).Ten patients dropped out (see Figure 1).Of the 33 patients who expressed an interest in being interviewed, 13 were contacted by the researcher and participated.Seven psychologists attended the focus group.Two were unable to attend.

| Demand
Figure 1 shows the flow chart of the referral process and enrollment for the study.In 15 months, 728 cancer patients were referred for psychological help, of whom 84 were patients in the general hospital who were seen by psychologists who were not participating in the study.This resulted in referral data from 644 patients (mean age 53.11 years; 77% female).Eligibility for SWORD indicated by psychologists was 13% (n = 81/644).The main reasons for not being eligible were having advanced cancer (18%), undergoing cancer treatment (28%), having no clinical significant FCR (19%), having no need for help with FCR (33%), or an indication for another intervention (17%).SWORD was offered to 80 patients.Four eligible patients were not offered SWORD and three patients who were not eligible were offered SWORD (see flowchart).The uptake was 79% (n = 63/80) and the completion rate 73% (n = 46/63).The willingness to participate in the questionnaire study was 94% (59/63).The eligibility was similar between the different centers.The uptake was lower in the POC (66%) compared to the general hospital (100%) and the university hospital (91%).Most of the reasons for patients deciding not to follow SWORD after being offered the intervention were not related to its characteristics.Instead, the reasons included having no need for help, not being willing to participate in a study, preferring treatment elsewhere, or making a shared decision with the psychologist for treatment which prioritized aspects other than FCR (see flowchart).The POC had the highest number of patients treated with SWORD (n = 31), compared to the general hospital (n = 12) and the university hospital (n = 20).

| Statistical effectiveness
The baseline psychological variables of the study sample (n = 59) are displayed in Table 2.The baseline CWS-6 scores were not significantly different between the various centers (F = .260, p = 0.772).

| Clinically significant improvement
Four patients (8%) had an increase in CWS-6 of one or two points, which was below the threshold of reliable change.Of the 45 patients with a reduction in the CWS-6, 21 patients (43%) had a clinically significant improvement.The proportion of participants with reliable change, clinically significant change, and clinically significant improvement in the three centers is displayed in Table 3

| Self-reported effectiveness
Among those who completed the study (n = 49), 8% reported complete recovery, 82% partial improvement, 8% no improvement, and 2% deterioration in FCR.Furthermore, 88% felt more control over their FCR and 86% could cope better with stressful situations.The treatment goals were fully achieved by 22%, largely by 45%, partially by 31%, and not at all by 2% of participants (Table 3).In the qualitative data, therapists and patients reported that treatment results were not always visible in a reduction in FCR.Instead, they described more insight in and acceptance of fear, an increased sense of control over FCR, more tools to cope with fearful situations, and less interference of FCR with daily life.For example, in their ability to make future plans, to avoid fearful situations less often, and having more energy.

| Dose
Forty three participants (75%) received all eight sessions (Table A1).The reasons for dropping out of intervention included a sufficient reduction in FCR, a cancer recurrence, no match T A B L E 2 Baseline questionnaire data (n = 59) and effect of treatment on primary and secondary outcomes in study completers (N = 49).

| Fidelity
The median length in minutes of sessions one and two and the online sessions was longer than prescribed in the manual (Table A2).Reasons included requiring more time to cover the manual, or other topics introduced by the patient.The interval, in days, between all sessions followed the manual.Live sessions were relatively often switched to remote contact.Reasons included patient preference and Covid-19 restrictions.Fidelity to the core components varied from 81.52% in session 6%, to 95.56% in session 1. Reasons to deviate included time constraints and there being no match between the patient and core component.In several cases, participants received other psychological interventions, predominantly focused on trauma.Adherence to sessions' lengths and intervals between them was high in the POC, varying in the general hospital, while in the university hospital, all sessions were longer than prescribed.In the POC approximately 50% of the live sessions were delivered remotely.Adherence to core components was highest in the university hospital, followed by the POC, and the general hospital.

| Patients
In general, 92% of patients were satisfied with SWORD with an average grade of 8.2/10.In total, 76% preferred the blended format over face-to-face therapy (20%) or eHealth only (4%) as this format helped them to consolidate the information.A combination of live and remote sessions was preferred by 49%, over live (47%), or remote (4%) only.Regarding structure, most patients (76%) were satisfied with the duration of treatment and felt the structured format provided clarity and overview.However, some felt there was little room to discuss topics outside the manual and rated too high the number of home exercises.Regarding content, the usefulness of exercises is displayed in Table A3.

| Practicality
Psychologists reported having sufficient knowledge and skills for SWORD.This was also the impression of patients.The therapist training of 8 hours was regarded as helpful.However, shorter training was suggested as a more feasible option, combined with an e-learning, and learning by doing.The latter, however, may not always enjoy sufficient case load and time.The external supervision sessions for SWORD were viewed as a 'luxury' as centers already had sufficient supervision structures.The CWS-6 was regarded as a helpful tool to identify whether patients had an elevated FCR.
However, the guiding questions were not seen as having additional value to the existing assessment.Most questions from therapists had related to the assessment, including medical criteria, and psychological contra-indications.Questions also concerned deviations from the treatment manual.Psychologists assumed they had to follow the manual strictly, both because it was evidence-based and because they participated in an intervention study.In the POC, the knowledge and skills of non-registered psychologists, combined with the SWORD training, treatment manual, and regular local supervision by registered healthcare psychologists, were regarded as sufficient to deliver SWORD.

Assessment
The intake and assessment procedure differed across settings.There was one intake appointment in the general hospital but two in the other settings.Meanwhile the general hospital was the only setting where a discussion among psychologists of treatment indication took place.Not all psychologists worked with SWORD in the general hospital which may have led to inadequate assessment.In all settings practical and technical issues hindered the integration of the CWS-6 in digital routine outcome measures.In the general hospital, it was not administered on paper due to time constraints.

Intervention
The specific planning of appointments did not fit with some setting procedures.The POC did not have sufficient registered psychologists to deliver SWORD.The natural turnover of psychologists in all centers hindered the supply of SWORD.Working with the eHealth platform was easily integrated into the standard operating procedures in all three settings.

| Sustainability
Patients, psychologists, and management in all centers had a positive attitude toward continuing SWORD.They valued evidence-based care, deemed FCR an important problem, and saw the benefits of treatment manuals for the efficiency of care.Meanwhile, the SWORD consultations fitted within existing healthcare insurance.The experience with, and knowledge of SWORD, gained throughout the study was sufficient to ensure its implementation.A coordinating psychologist advocating SWORD was essential in each center.However, the eHealth platform for SWORD was a crucial barrier to sustainability as centers already worked with another provider.The installing and monthly therapist user license costs involved in having a contract with a second provider, and the centers' eHealth regulations, were the reason that two of the three centers did not continue SWORD.

| DISCUSSION
We evaluated the feasibility of implementing the SWORD intervention and its assessment for clinical FCR in real-world psychooncology practice.The implementation of SWORD was deemed feasible despite differences between healthcare settings on all feasibility outcomes.With regard to demand, this study offers insight in the actual number of patients in each of the psycho-oncology services who have a need for help with FCR, and are eligible and willing.The uptake of SWORD was 79%.Similar to the results of the RCT, 12 SWORD was effective in reducing FCR in actual practice with large effect size and no adverse events in terms of increasing scores larger than the RCI.The degree of execution showed that there was variability in session planning, length, and modality, while adherence to the content of the manual was high.Both patients and psychologists were satisfied with SWORD (acceptability), valuing its blended format, and its guidance and efficiency.It was deemed practical to deliver SWORD by psychologists given their existing knowledge and skills.However, the guiding questions for assessing clinical FCR were considered redundant.SWORD was well integrated into existing organization infrastructure, but the CWS-6 for assessing FCR was not.
We observed differences in the organization of care, assessment and treatment with SWORD in three different settings.In particular, the uptake was lowest in the POC, possibly because eligibility for SWORD was assessed less strictly before offering SWORD to patients.Despite differences, SWORD fitted within all the different types of centers.The effectiveness of SWORD was the same in each indicating that differences did not compromise the effect of treatment.Therefore, we suggest that in future implementation, factors other than the type of setting should be the major consideration when deciding where to implement SWORD.Factors such as how many patients can be treated, the organization's accessibility and willingness and preparedness for implementation should be paramount. 28 the current sample, patients were recruited in psychooncology services and clinically assessed by a psychologist for FCR, their motivation, and need for help.The RCT sample, however, was recruited from oncology follow-up care and only screened with a questionnaire score.In our sample, patients were relatively younger, more often women, and had a shorter time since medical treatment than RCT participants.Almost half of the patients had breast cancer, while other cancer diagnoses were relatively equally distributed.
These results though consistent with other FCR intervention studies 1 might indicate that men, older patients, and those with other cancer types than breast cancer, less often seek, or get referred for help with FCR.This could warrant action to improve the access of these groups to psychological care.
The effectiveness of SWORD remained high in actual practice, while it is assumed that effectiveness decreases outside RCT settings where the internal validity is compromised. 29We assume that clinical assessment produced a sample with clinically relevant FCR, a considerable need for help, and intrinsic motivation to follow SWORD, which might have contributed to treatment success.This is supported by baseline FCR scores which were higher than in the RCT.The qualitative data of this study highlight the challenge for psychologists to balance treatment fidelity with flexibility.Psychologists had the idea that deviation from the manual would reduce the effectiveness of the evidence-based intervention.In contrast, quantitative data show that several significant modifications were made, such as omitting core components and adding treatment sessions and other interventions.The large number of online consultations were likely to have been a consequence of the Covid-19 restrictions rather than non-adherence.These results are consistent with the expected concerns psychologists reported in a previous SWORD study. 14kewise, in a study investigating the barriers and facilitators for the sustainable delivery of the FCR intervention ConquerFear, 14 some psychologists preferred to use the manual in a flexible way, making changes similar to the therapists here.Another study reported that evidence-based treatments in psychosocial oncology practice are often adapted to the patients' needs. 31Together, these studies reflect the tension between the wish to implement evidence-based interventions 10 and an increased call for personalized care. 32From a research perspective, it is important to understand how deviations from evidence-based manuals affect the effectiveness of care.This includes studies evaluating the effectiveness of tailored care, such as by Harnas et al. 32 From an implementation perspective, we recommend bringing existing evidence-based interventions into practice, maintaining fidelity with core components, while equipping psychologists to make these interventions more personal. 14,33e uptake of FCR interventions is highly dependent upon HCPs identification of clinical FCR and their referral to psychological services.Psychologists here reported that referrals were rarely specifically for FCR.Patients, likewise, reported that FCR was insufficiently addressed in medical consultations.Referral may, however, have been affected by the Covid-19 restrictions during the study period.
Medical follow-up appointments were scaled down and provided by phone, increasing the threshold to discuss mental health issues.
However, the barrier of poor identification and referral is consistent with previous implementation studies within FCR 28,34 and psychooncology 3,31,[35][36][37] and with a previous SWORD study. 14While improving referral was not a primary target of this study, we developed an educational video for HCPs to overcome the barrier of a lack of knowledge of FCR. 14 However, this video had a low reach as there was no formal strategy to ensure dissemination.A personal approach, in which study psychologists informed referrers, with whom they already collaborated, about SWORD, was more successful.This is in line with literature advocating the use of local champions, 35 and multi-disciplinary communication 31 to support implementation.In order to improve FCR identification, a more structural, multidimensional approach is required, targeting HCPs, patients and organizational structures. 2,14e benefits of blended care, 14,37,38 combining the advantages of online exercises with offline psychological guidance, were confirmed by both patients and psychologists.However SWORD after the study.The importance of organizations' willingness to invest in an innovation have been reported elsewhere. 28,36,37An implementation strategy should include informing institutions about the relevance and benefits of SWORD, which might outweigh the costs.At the same time, this requires a more centralized approach 39 in which developers of eHealth interventions, funders, eHealth providers, and psycho-oncology services work together to make eHealth more accessible.

| Strengths and limitations
Our study used four different data collection methods, across six domains, from a well-known feasibility framework.This included the perspectives from both patients and psychologists thus increasing its results' credibility.A key strength was the representation of different healthcare settings, demonstrating the complexity of oncological practice. 2A limitation of our study was that it was conducted during the Covid-19 pandemic, which might have limited the generalizability of the results.However, these developments were well documented throughout the study, allowing us take them into account when interpreting the results.Second, some patients dropped out of the study so we could not include their experiences.However, regarding effectiveness, we performed sensitivity analyses that yielded similar results.Third, the POC had 10 weeks less to offer SWORD than the other centers.We know through registry of referrals that only two eligible patients were missed during these weeks.Fourth, due to practical constraints, fidelity to the manual was self-reported by psychologists using the session checklists.This is less reliable than an DEUNING-SMIT ET AL.

BOX 1 BOX 2 months prior 3 .
Adaptations to SWORD Adaptation to different tumor types -Adapting tumor-specific language to neutral language -Making patient videos without tumor-specific language -Removing the theme heredity Therapy content -Session 1 shortened to a regular treatment session (60 min) as the assessment of the patient background is already covered in the intake session as part of usual care -Elements of acceptance and commitment therapy added (e.g.values exercise, use of metaphors) -Exercise about social environment repeated and extended -More variation in patient videos (e.g.sex, age) and more focus on positive examples -'what do I want to discuss the next session' added as repeated homework exercise Format/design -More variation in information presentation (e.g.text alternated with videos, more use of graphics) -Texts shortened and wording simplified eHealth platform -Use color scheme and logo of treating center to increase trustworthiness -Option to print exercises Other -Online session changed from chat to video-conferencing -Treatment criteria updated according to recent literature about clinical FCR; guiding questions formatted Updated treatment indication for SWORD 1. Age >18 years 2. Medical situation a. Received cancer treatment with curative intent b.Primary medical treatment completed at least 6 Clinical significant fear of cancer recurrence a. * High levels of fear/worry/preoccupation for cancer recurrence (supported by, but not restricted to a Cancer Worry Scale-6 score ≥12) b. * The fear/worry/preoccupation is persistent c.Hypervigilance to bodily symptoms d.Dysfunctional coping e. Limitations in daily life * needs to be present 4. Other treatment criteria a.Having a need for help with FCR b.FCR is the primary psychological problem c.Being motivated and personal circumstances allow to actively participate in SWORD d.No severe psychological comorbidity that limits the ability to follow SWORD (e.g.current depression or personality disorder) Note: italic criteria are different from the original study.DEUNING-SMIT ET AL.

F I G U R E 1
Flowchart showing steps in the care process (white boxes) and study enrollment (gray boxes).* Not all referred patients were seen by study psychologists, ** Psychologists could select multiple reasons.

3. 7 | 3 . 7 . 1 |
Integration The compatibility with infrastructure and resources Referral Hospitals received internal referrals from specialists and nurse specialists.The POC received referrals from general practitioners and hospitals.In the university hospital many cancer patients participated in a multidisciplinary oncological rehabilitation program where the psychologist involved in our study identified patients who could benefit from SWORD.HCPs discussed mental health, but not specifically FCR.Neither did they refer for it.Throughout the study, the hospital psychologists took action to improve FCR awareness among specialists, which improved referral.The video for HCPs was difficult to share within the existing infrastructure.In all three centers, the Covid-19 pandemic and associated restrictions led to fewer psychooncology referrals.
, a crucial barrier to overcome when implementing eHealth interventions included the willingness of organizations to contract eHealth platforms.The distribution of psychological interventions across different commercial eHealth platforms means that institutions have to pay multiple license fees.This is often not covered by healthcare reimbursement models, leading two of the three participating centers to discontinue Baseline demographic and medical characteristics of study participants.
. Reliable change was approximately equal between the centers and clinically significant change was highest in the university hospital.DEUNING-SMIT ET AL.T A B L E 1 a Most frequent comorbidities: back pain (44%), arthrosis (24%), hypertension (22%), and depression (22%).
Key elements that stood out were the videos offering peer support which provided recognition and positive examples.The thought report too was highlighted, which many patients kept using after SWORD.The mindfulness and relaxation exercises were highly valued by some, but not others.Two patients with an ongoing cancer diagnosis felt no connection with the videos and examples.The eHealth platform was felt easy to use (81%) The high frequency of sessions was demanding but improved the progress of treatment.Regarding content, the patient videos were a valuable component, resembling contact with peers.The personal FCR model helped therapists to gain insight into the individual's FCR.However the hierarchy of fear for behavioral experiments was not considered to be in line with current CBT guidelines.The eHealth platform layout and functionality were regarded as positive, but occasionally technical problems were encountered.