Metacognitive Processes in Cancer: A Review

Abstract When diagnosed with cancer, the patients and their family go through emotional turmoil across the different phases: diagnosis, assessment, treatment, and aftercare, which decrease their quality of life and well-being. Previously, many studies have highlighted the association of metacognition with the development and maintenance of mental health conditions. Several recent studies have pointed out the significant role of dysfunctional metacognitive beliefs in the context of chronic disease. Thus, the present study aims to explore the role of metacognitive processes in cancer. The researchers conducted a narrative review of literature using PubMed, Semantic Scholar, and Science Direct. A total of 31 articles were selected and analyzed. This review article established that patients with cancer and caregivers experience metacognitive beliefs, which are associated with emotional distress, and the effectiveness of metacognitive therapy in reducing distress. This study also provides insight into the broader scope to advance research in this field.


Metacognitive Processes in Cancer
Metacognition is a higher order cognitive function where an individual actively evaluates, monitors, and controls their cognitive processes. 1 John Flavell coined the term "metacognition" as a self-regulatory learning process. 2 However, since its conceptualization, metacognition has gained much attention across various disciplines. 1 The metacognitive skills are used for problem-solving, 3 decision making, 4,5 critical reasoning, 6 and coping with emotional stressors. 7 Researchers have highlighted the role of the metacognitive beliefs in the development and maintenance of mental health conditions mainly depression and anxiety using the self-regulatory executive function (S-REF) theory. 8,9 According to the S-REF theory, positive metacognitive beliefs, i.e., "worry is helpful," increase negative thoughts and expose the person to view a situation as more threatening, and negative metacognitive beliefs about the uncontrollability and danger of the worrying, maintain the worry. 10 Both metacognitive beliefs reinforce cognitive attentional syndrome that comprises three processes: (1) perseverative thinking such as worry, rumination, and over-analyzing events, (2) inflexible self-focused attention to threatful events, (3) maladaptive coping strategies that impair cognitive and emotional regulation; thereby, maintaining the emotional distress. The association of metacognitive beliefs is also linked in development of anxiety and depression across different chronic medical conditions, 11,12 due to which quality of life is compromised. 13 As cancer is a common chronic physical health condition and has been found to have association with mental health conditions such as depression, 14,15 through this review article, we try to understand the role of metacognitive processes in patients with cancer and caregivers at different phases (diagnosis, assessment, treatment, aftercare) of cancer.

Methods
We conducted a narrative review of literature to explore the metacognitive processes in patients with cancer and caregivers. Articles were selected using PubMed, Semantic Scholar, and Science Direct. The search term included "metacognition and cancer," "metacognitive processes and cancer," "metacognitive beliefs and cancer," "metacognitive Keywords ► metacognition ► cancer ► chronic medical conditions Abstract When diagnosed with cancer, the patients and their family go through emotional turmoil across the different phases: diagnosis, assessment, treatment, and aftercare, which decrease their quality of life and well-being. Previously, many studies have highlighted the association of metacognition with the development and maintenance of mental health conditions. Several recent studies have pointed out the significant role of dysfunctional metacognitive beliefs in the context of chronic disease. Thus, the present study aims to explore the role of metacognitive processes in cancer. The researchers conducted a narrative review of literature using PubMed, Semantic Scholar, and Science Direct. A total of 31 articles were selected and analyzed. This review article established that patients with cancer and caregivers experience metacognitive beliefs, which are associated with emotional distress, and the effectiveness of metacognitive therapy in reducing distress. This study also provides insight into the broader scope to advance research in this field. therapy and cancer," "metacognitive intervention and cancer," "metacognition and cancer caregivers," and "metacognition and caregiving in cancer." We included all types of articles published in the English language from 2012 to 2022. Search for the articles was not restricted to any specific age group, cancer type, cancer stage, or country. Author R.R. performed the literature search and selected papers for the review first based on the titles and then based on the abstracts before reviewing the full texts. All the duplicate articles were removed. Uncertainties related to the relevance of the articles were discussed between the authors. Data extraction included publication information (title of the paper, authors, year of publication), sample characteristics (number of participants, age group, gender, cancer type, phase of cancer, country), research design used, and the findings.

Literature Search Results
The last search was performed on November 14, 2022. After rigorous search for articles and removal of duplicates, a total of 31 articles were included in the study. Studies on metacognition in cancer have been conducted using different study designs (cross-sectional, case-control, experimental designs, qualitative, longitudinal, and theoretical paper) on various forms of cancer (breast, ovarian, liver) among adolescents, young adults, and old adults. From our literature search, we found 7 studies investigated the impact of metacognition on fear of cancer recurrence, 10 studies discussed the benefits of the metacognitive therapy on patients with cancer, and 1 study validated the metacognitive scale for use in the cancer population. Only two studies investigated role of metacognition in caregivers. We also identified that studies on metacognition in patients with cancer had been conducted in United States, UK, Italy, Australia, Iran, Turkey, Hong Kong and China (►Table 1).

Tools to Assess Metacognitive Beliefs
There are several tools to measure metacognition; however, in our analysis, we found most studies used Metacognition Questionnaire-30 (MCQ-30) 16 to assess metacognitive beliefs in patients with cancer. The scale is the short version of the Metacognition Questionnaire (MCQ-65). 17 It comprises five sub-scales that include: (1) positive beliefs about worry (PB), e.g., "Worrying helps me to avoid problems in the future," (2) negative beliefs about the uncontrollability and danger of worry (NB), e.g., "My worry is dangerous for me," (3) beliefs about the need for control of thoughts (NFC), e.g., "It is bad to think certain thoughts," (4) beliefs concerning cognitive competence (CC), e.g., "I have a poor memory," and  ). Therefore, the total score for the scale ranges from 30 to 120 and 6 to 30 for each subscale. The MCQ-30 scale has also been adapted in several languages, Turkish, 18 Italian, 19 and Polish, 20 and can also be used for children 21 and adolescents. 16 A recent study 22 validated MCQ-30 and found that the scale has good internal consistency and is valid for use among patients with breast and prostate cancer. Evidence regarding the scale's validity in assessing metacognition in patients diagnosed with other forms of cancer is lacking.

Metacognitive Beliefs Result in Emotional Distress
Patients with cancer have impaired metacognitive functions. 23 They ruminate about cancer-related worries, its consequences on them and other family members, financial problems, family members' illness, and neighbor disputes. 24 Based on the S-REF theory, a study has found positive metacognitive beliefs related to worry and negative metacognitive beliefs related to uncontrollability and danger of worry are significantly higher in the patient group than the control group. 23 Anxiety and depression in patients with cancer are associated with positive and negative metacognitions. 25 However, the negative metacognitive beliefs compared to positive metacognitive beliefs have larger contribution to the development of anxiety and depressive symptoms after diagnosis 26 and while undergoing chemotherapy. 19,[27][28][29] This suggests that though positive metacognitive beliefs initially guide a patient to worry but negative metacognitive beliefs maintain the worry by activating meta worry (worry about worry), which further intensifies the worry. 26 Another study found that metacognitive beliefs present after cancer diagnosis and before treatment predict depression, anxiety, and trauma in patients with cancer even after 1 year of diagnosis. 30 People diagnosed with cancer at a young age show severe anxiety symptoms, and a study suggests that it is due to the negative metacognitive beliefs about uncontrollability and the danger, which are found to be significantly higher in young people who have cancer than in adults. 31 Another study revealed negative metacognitive beliefs are heightened at 12 months of diagnosis and between 24 to 36 months postdiagnosis, suggesting patients with cancer engage in negative metacognitive beliefs mainly after primary treatment and after the treatment when they fear cancer recurrence. 32 Negative metacognitive beliefs are also higher in patients in the early stage of cancer than in patients in the advanced stage. 27 Caregivers of the patients diagnosed with cancer also experience positive and negative metacognitive beliefs, which are associated with a lower score in subjective well-being. 33 In young adult female cancer survivors, metacognitive beliefs were associated with their reproductive concerns such as fertility potential, partner disclosure, child's health, personal health, acceptance, and being pregnant. 34

Fear of Recurrence in Patients with Cancer
The metacognitive aspects are also linked to patients' fear of cancer recurrence. 35

Metacognitive Therapy for Cancer Treatment
Metacognition therapy administered individually or in a group is effective in challenging metacognitive beliefs and thereby is helpful in the treatment of depression, anxiety, posttraumatic symptoms, worry and rumination, sexual functioning, sleep disorder, fear of recurrence, and improves the quality of life in patients with cancer undergoing primary treatment. [41][42][43] The main objective of metacognitive therapy is to modify the metacognitive beliefs that maintain negative thinking styles and coping strategies. Metacognitive therapy typically includes 5 to 10 sessions 10 and in a study it was found that delivery of metacognitive therapy including six sessions helps in reducing emotional distress in patients with cancer. 42 The therapist identifies the positive and negative metacognitive beliefs in the first two sessions and generates a case formulation. The patient is then psycho-educated about their rumination time and thinking process, including the emotional consequences of it. From, the S-REF theory, we understand that modifying negative metacognitive beliefs is crucial as once an individual views their worry as uncontrollable, they have difficulty to control it. 10 Therefore, in the third, fourth, fifth, and sixth sessions, patients are taught and asked to practice attention training techniques, detached mindfulness, rumination postponement, modifying negative meta beliefs, and then the positive metacognitive beliefs using verbal methods, rumination modulation experiment, advantage-disadvantages analysis, and behavioral experiments. In the last session, the focus is on relapse prevention. Before administration of metacognitive therapy, participants reported being caught in a spiral of worry making them feel helpless, hopeless, and overwhelmed but, after the therapeutic intervention, they found themselves accepting and controlling their thoughts effectively and gained a sense of freedom to live lives free from fear about cancer and other challenges of survivorship. 24 It was observed that with the use of metacognitive therapy recovery status is maintained even after 1 month 43 to 6 months of follow-up 41,42 in adult cancer survivors and in adolescent and young adult cancer survivors. 44 A comparative study found that though metacognitive therapy is effective in reducing depression, anxiety, and stress symptoms in patients with breast cancer, mindfulness-based therapy has maximum effectiveness on emotion function, pain symptoms, and fatigue. 45,46 A study also made an attempt to integrate mindfulness and metacognitive-based therapy for patients with cancer and the result suggested effectiveness of integrating both therapeutic approaches in reducing distress, anxiety, depression, and posttraumatic symptoms. 35 In another study, it was found that positive thinking training effectively reduces metacognitive beliefs in patients with breast cancer. 47 To address the chemotherapy-induced cognitive impairment, a study found that Cognitive Orientation to Daily Occupational Performance (CO-OP), a type of metacognitive strategy training, has positive effect on cognitive performance and neural connectivity in women with breast cancer. 48 A

Discussion
This review article focused on the metacognitive processes in patients with cancer and caregivers. The study findings suggest that patients diagnosed with cancer suffer from emotional distress, depression, anxiety, and posttraumatic symptoms, and metacognitive beliefs play a significant role in developing and maintaining them, notably, the negative meta beliefs. 25 As the S-REF theory suggests both positive and negative metacognitive beliefs result in emotional distress; however, the role of negative metacognitive beliefs is crucial as once an individual view their worry as uncontrollable, they are unable to control it and feel helpless, hopeless, and get overwhelmed with worry. 10 Therefore, findings of several studies suggest a strong association between negative metacognitive beliefs with depression and anxiety. 23,26 Negative metacognition has been observed with young patients, 31 also among patients who were in early stages of cancer, 27 and received chemotherapy. 19,[27][28][29] This is because adults who are young or are in early stage of cancer are more worried about the prognosis and fear about negative consequences such as fear of recurrence. 27,31 Similarly, patients who received chemotherapy are aware of its negative effects on health, i.e., nausea, weakness, hair loss, and loss of appetite. They understand that they have to be at home while the treatment is continuing, have to visit hospitals frequently to receive treatment, and they also experience uncertainty about recurrence of cancer which may suggest their higher scores in negative metacognitive beliefs than patients receiving radiotherapy or going through operation. 27 Emotional distress, worry, ruminative thoughts, and symptoms of depression were also observed among family caregivers of patients diagnosed with cancer 50,51 and since family caregivers' support has great influence in the cancer treatment, it is important to understand their metacognitive beliefs. However, from our literature search, we found studies on metacognitive processes in caregivers are limited. We found two studies assessing metacognitive beliefs in caregivers indicating both positive and negative metacognitive beliefs are associated with subjective well-being 33 and psychological resilience. 37 Therefore, it is important to address metacognitive beliefs of caregivers and help them in dealing with the stressful situation and improving their quality of life.
We also focused on the benefits of the metacognitive therapy in patients with cancer. It was found that metacognitive therapy is effective in reducing emotional distress, anxiety, posttraumatic symptoms, and fear of recurrence in patients with cancer. [41][42][43] We also found studies comparing the effectiveness of mindfulness-based therapy and metacognition therapy. 45,46 From the comparison, it was evident that though mindfulness-based therapy reduced emotional distress in patients, however, the positive impact of the treatment was not observed in follow-up. 45 Again, another study attempted to integrate both mindfulness-based therapy and metacognition therapy and found taking both therapeutic approaches together had better outcomes rather than administering only one of the therapeutic approaches. 35 Also, one study found out the effectiveness of positive thinking training in reducing metacognitive beliefs. 47 There are other therapies such as Acceptance Commitment-Based Therapy 52-54 and Cognitive Behavior Therapy 55,56 that are used to treat emotional distress in patients with cancer. However, from our literature search we did not find any comparative studies to understand the effectiveness of metacognitive therapy with the other therapies. Also, we did not find any other studies integrating with metacognitive therapy other than mindfulness-based therapy. It would have been interesting to observe the outcome of using metacognitive therapy with complementary therapies like Art Therapy 57,58 and Dance Movement Therapy. 59 Metacognition has also been used as a strategy for improving executive function in patients who underwent chemotherapy 48 and can be used as an education tool to promote self-care practices in patients with breast cancer. 49 It was also noted that studies included for review used MCQ-30 as a tool to assess metacognitive beliefs in patients with cancer. A study validated the scale in 2014 for use among patients patients diagnosed with breast and prostate cancer, limiting its use across different cancer diagnoses. 21 Although MCQ-30 has been used to a great extent to assess metacognitive beliefs in research studies, nevertheless, researchers can work on developing effective tools to assess metacognitive beliefs by taking participants with other forms of a cancer diagnosis.
Further, as mentioned above, we found limited countries conducted studies to understand the role of metacognition in patients diagnosed with cancer. We identified seven studies conducted each in UK and Italy, two studies each in Australia and Hong Kong, five in Iran, three in Turkey, and one study each in United States, and China. From our search results, we did not find studies conducted on the Indian population to know how metacognitive beliefs influence the psychological condition of people diagnosed with cancer and how therapy or specific strategies can be used to minimize the distress caused by the disease. This suggests that metacognition is still an emerging concept in health psychology, and looking at its contribution during diagnosis, treatment, and recovery, more research should be promoted in this area. In India, cancer cases are on the rise 60,61 ; therefore, to improve the quality of life of patients diagnosed with cancer and to contribute to the pool of Indian scientific research, young researchers can explore the significance of metacognitive aspects in patients diagnosed with cancer in India.

Limitation
In this review article, researchers used more than one search database and included studies on different research designs. We did not limit the search for studies to any age group, cancer type, cancer stage, or country. However, the studies included have not been assessed for methodological quality and risk of bias. Despite this, the findings of the study will help in advancing research studies in this area and mental health professionals, specifically working in the field of oncology.

Conclusion
This review helped us understand that patients with cancer experience metacognitive beliefs at different phases of cancer, i.e., before the primary treatment, during treatment, and after treatment, and metacognitive therapy contributes significantly to reducing emotional distress observed among patients with cancer. Hence, to improve the quality of life of patients with cancer and caregivers, research on metacognitive processes in cancer should be promoted.