Cancer‐related fatigue is reported as the most common and distressing symptom experienced by patients with cancer. It can exacerbate the experience of other symptoms, negatively affect mood, interfere with the ability to carry out everyday activities, and negatively impact on quality of life. Educational interventions may help people to manage this fatigue or to cope with this symptom, and reduce its overall burden. Despite the importance of education for managing cancer‐related fatigue there are currently no systematic reviews examining this approach.Objectives
To determine the effectiveness of educational interventions for managing cancer‐related fatigue in adults.Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), and MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, OTseeker and PEDro up to 1st November 2016. We also searched trials registries.Selection criteria
We included randomised controlled trials (RCTs) of educational interventions focused on cancer‐related fatigue where fatigue was a primary outcome. Studies must have aimed to evaluate the effect of educational interventions designed specifically to manage cancer‐related fatigue, or to evaluate educational interventions targeting a constellation of physical symptoms or quality of life where fatigue was the primary focus. The studies could have compared educational interventions with no intervention or wait list controls, usual care or attention controls, or an alternative intervention for cancer‐related fatigue in adults with any type of cancer.Data collection and analysis
Two review authors independently screened studies for inclusion and extracted data. We resolved differences in opinion by discussion. Trial authors were contacted for additional information. A third independent person checked the data extraction. The main outcome considered in this review was cancer‐related fatigue. We assessed the evidence using GRADE and created a 'Summary of Findings' table.Main results
We included 14 RCTs with 2213 participants across different cancer diagnoses. Four studies used only 'information‐giving' educational strategies, whereas the remainder used mainly information‐giving strategies coupled with some problem‐solving, reinforcement, or support techniques. Interventions differed in delivery including: mode of delivery (face to face, web‐based, audiotape, telephone); group or individual interventions; number of sessions provided (ranging from 2 to 12 sessions); and timing of intervention in relation to completion of cancer treatment (during or after completion). Most trials compared educational interventions to usual care and meta‐analyses compared educational interventions to usual care or attention controls. Methodological issues that increased the risk of bias were evident including lack of blinding of outcome assessors, unclear allocation concealment in over half of the studies, and generally small sample sizes. Using the GRADE approach, we rated the quality of evidence as very low to moderate, downgraded mainly due to high risk of bias, unexplained heterogeneity, and imprecision.
There was moderate quality evidence of a small reduction in fatigue intensity from a meta‐analyses of eight studies (1524 participants; standardised mean difference (SMD) ‐0.28, 95% confidence interval (CI) ‐0.52 to ‐0.04) comparing educational interventions with usual care or attention control. We found low quality evidence from twelve studies (1711 participants) that educational interventions had a small effect on general/overall fatigue (SMD ‐0.27, 95% CI ‐0.51 to ‐0.04) compared to usual care or attention control. There was low quality evidence from three studies (622 participants) of a moderate size effect of educational interventions for reducing fatigue distress (SMD ‐0.57, 95% CI ‐1.09 to ‐0.05) compared to usual care, and this could be considered clinically significant. Pooled data from four studies (439 participants) found a small reduction in fatigue interference with daily life (SMD ‐0.35, 95% CI ‐0.54 to ‐0.16; moderate quality evidence). No clear effects on fatigue were found related to type of cancer treatment or timing of intervention in relation to completion of cancer treatment, and there were insufficient data available to determine the effect of educational interventions on fatigue by stage of disease, tumour type or group versus individual intervention.
Three studies (571 participants) provided low quality evidence for a reduction in anxiety in favour of the intervention group (mean difference (MD) ‐1.47, 95% CI ‐2.76 to ‐0.18) which, for some, would be considered clinically significant. Two additional studies not included in the meta‐analysis also reported statistically significant improvements in anxiety in favour of the educational intervention, whereas a third study did not. Compared with usual care or attention control, educational interventions showed no significant reduction in depressive symptoms (four studies, 881 participants, SMD ‐0.12, 95% CI ‐0.47 to 0.23; very low quality evidence). Three additional trials not included in the meta‐analysis found no between‐group differences in the symptoms of depression. No between‐group difference was evident in the capacity for activities of daily living or physical function when comparing educational interventions with usual care (4 studies, 773 participants, SMD 0.33, 95% CI ‐0.10 to 0.75) and the quality of evidence was low. Pooled evidence of low quality from two of three studies examining the effect of educational interventions compared to usual care found an improvement in global quality of life on a 0‐100 scale (MD 11.47, 95% CI 1.29 to 21.65), which would be considered clinically significant for some.
No adverse events were reported in any of the studies.Authors' conclusions
Educational interventions may have a small effect on reducing fatigue intensity, fatigue's interference with daily life, and general fatigue, and could have a moderate effect on reducing fatigue distress. Educational interventions focused on fatigue may also help reduce anxiety and improve global quality of life, but it is unclear what effect they might have on capacity for activities of daily living or depressive symptoms. Additional studies undertaken in the future are likely to impact on our confidence in the conclusions.
The incorporation of education for the management of fatigue as part of routine care appears reasonable. However, given the complex nature of this symptom, educational interventions on their own are unlikely to optimally reduce fatigue or help people manage its impact, and should be considered in conjunction with other interventions. Just how educational interventions are best delivered, and their content and timing to maximise outcomes, are issues that require further research.
Sally Bennett, Amanda Pigott, Elaine M Beller, Terry Haines, Pamela Meredith, Christie Delaney
Plain language summary
Education for the management of cancer‐related fatigue
This systematic review sought to find out how well educational interventions worked for managing cancer‐related fatigue.
Fatigue is a common and problematic symptom for people with cancer that is greater than the tiredness experienced in everyday life. It can make the experience of other symptoms worse, negatively affect mood, interfere with the ability to carry out everyday activities, and negatively impact on quality of life.
Education can provide people with information about what fatigue is and how to manage it. For example, managing fatigue may involve conserving energy throughout the day, and learning about the benefits of exercise, diet, relaxation, and good sleep routines. These approaches may help people to manage their fatigue and help them cope with its effects. In November 2016 we found 14 trials using education for cancer‐related fatigue compared to the usual care people received or to an attention control such as providing general information about cancer. All of the included studies were randomised controlled trials. These trials were undertaken with adults with any type or stage of cancer.
The review found that education may have a small effect on reducing the intensity of fatigue, its interference in daily activities or relationships, and general (overall) fatigue. It could have a moderate effect on reducing distress from fatigue amongst people with non‐advanced cancer. There may also be beneficial effects on anxiety and overall quality of life, although it is unclear whether it reduces depression. It is unknown if this result might differ between types of cancer treatment or if the education is provided during or after cancer treatment. Not enough is known about the type of education that is most effective, when it is best provided, or whether it is effective for people with advanced cancer.
Quality of evidence
We rated the quality of the evidence from studies using four levels: very low, low, moderate, or high. Very low quality evidence means that we are very uncertain about the results. High quality evidence means that we are very confident in the results. There were problems with the design of some studies, and some were very small in size. The quality of the evidence therefore varied from very low to moderate overall and the results of this review need to be interpreted with caution.
Sally Bennett, Amanda Pigott, Elaine M Beller, Terry Haines, Pamela Meredith, Christie Delaney
Implications for practice
This review found some evidence from RCTs that educational interventions may have a small effect in reducing general (overall) fatigue, fatigue intensity, and fatigue interference, and may reduce the distress from fatigue. However the research is hampered by methodological issues that may mean the results are overestimated.For people with cancer
Knowing that fatigue is a common experience amongst those with cancer, and that it increases during treatment, may be reassuring for people with this symptom. Educational interventions can also help people develop knowledge and skills for managing fatigue such as pacing and prioritising daily activities.For clinicians
Researchers suggest that cancer‐related fatigue is under‐diagnosed and under‐treated (Jameson 2016; Smith 2007), in part due to health professionals thinking little can be done to manage it (Borneman 2007). Providing education about fatigue and its management appears to have some effect on this symptom and incorporating education as part of routine care seems reasonable. The NCCN guidelines recommend that screening for fatigue should occur for all people receiving treatment for cancer at their initial clinical visit and that education about cancer‐related fatigue be offered as soon as possible regarding the potential for fatigue to develop and possible treatment options (Koornstra 2014; NCCN 2016).For policy makers
Educational interventions may play a small role in reducing general (overall) fatigue, fatigue intensity, and fatigue interference, and may reduce the distress from fatigue. The incorporation of education for the management of fatigue as part of routine care appears reasonable, but given the complex nature of this symptom, educational interventions should be considered in conjunction with other interventions.For funders of the intervention
Costs associated with providing educational interventions for the management of cancer‐related fatigue are largely personnel costs. These costs are likely to differ depending on the nature of the specific educational intervention used. No cost‐effectiveness studies have been undertaken.
Implications for research General implications
Further research to understand the best approach to providing educational interventions for the management of cancer‐related fatigue is recommended. A number of specific implications for research are evident.
There was insufficient research to allow conclusions to be drawn with respect to the effect of educational interventions by tumour type, timing of intervention relative to completion of cancer treatment, stage of disease, type of cancer treatment being received, or delivery of the intervention by group versus individual formats. For these factors to be better understood, trials that are designed specifically to address these questions are needed. No studies were identified that specifically considered educational interventions with people with advanced cancer and this could be a focus for future research. The majority of studies involved participants with a mild to moderate level of fatigue. Whether studies targeted to those with moderate to severe fatigue would have greater impact on fatigue could also be considered.
People experiencing fatigue may benefit from the reassurance from face to face contact, however they may also appreciate support without having to leave home. The comparative benefits of different delivery options have not been tested. Asking preferences of those receiving treatment may be informative. Much remains to be understood about timing and formats of educational interventions for the management of cancer‐related fatigue. There have been no studies that have specifically considered the dose of the educational intervention and only a few (e.g. Barsevick 2004; Barsevick 2010; Foster 2015; Yates 2005) attempted to control for the potential effect of social support, time, and attention ‐ further issues to be considered in research.Measurement (endpoints)
A number of fatigue measures incorporate questions about fatigue distress and interference together with measurement of fatigue severity. There may also be an advantage to measuring these constructs separately. This can be understood if one considers that the intensity of fatigue a person might experience might not always be highly correlated with fatigue distress of interference from fatigue. For example, in a study with hospitalised medical‐surgical patients, Kris 2004 found that fatigue severity had only a moderate correlation (r = 0.52) with fatigue distress.
The relationship between depression and fatigue is unclear, but given the potential for people who have fatigue to develop depressive symptoms and that people who have depression are often more fatigued (Mitchell 2006), measurement of depression in future trials should be routine. No studies investigated the impact on work outcomes or cost‐effectiveness of the interventions and these could be considered in future research.Design
Large, well‐designed RCTs are needed to further investigate the effectiveness of educational interventions for managing cancer‐related fatigue. It was difficult to ascertain the details of methods used in many of these studies. Authors are urged to use the CONSORT guidelines (Schulz 2010; including its various elaborations) when planning their research and writing up their reports.Get full text at The Cochrane Library
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