Psychosocial interventions for reducing fatigue during cancer treatment in adults Stable (no update expected for reasons given in 'What's new')

Abstract

Abstract Background

Fatigue is a common symptom in cancer patients receiving active treatment. There are a limited number of reviews evaluating interventions for fatigue during active treatment, and they are restricted to patients with advanced cancer, or to patients during radiotherapy. To date there is no systematic review on psychosocial interventions for fatigue during cancer treatment.

Objectives

To evaluate if psychosocial interventions are effective in reducing fatigue in cancer patients receiving active treatment for cancer, and which types of psychosocial interventions are the most effective.

Search methods

In September 2008 we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), PUBMED, MEDLINE, EMBASE, CINAHL and PsycINFO, and checked the reference lists.

Selection criteria

Randomised controlled trials (RCTs) were included which evaluated psychosocial interventions in adult cancer patients during treatment, with fatigue as an outcome measure.

Data collection and analysis

Three review authors independently extracted data from the selected studies, and assessed the methodological quality using several quality rating scales and additional criteria.

Main results

Twenty‐seven studies met the inclusion criteria with a total of 3324 participants, and seven studies reported significant effects of the psychosocial intervention on fatigue. In three studies the effect was maintained at follow‐up. The quality of the studies was generally moderate. Effect sizes varied between 0.17 to 1.07.

The effectiveness of interventions specific for fatigue was significantly higher (80%) compared to interventions not specific for fatigue (14%). In five studies the interventions were specifically focused on fatigue, with four being effective. The five interventions were brief, consisting of three individual sessions, provided by (oncology) nurses. In general, during these interventions participants were educated about fatigue, were taught in self‐care or coping techniques, and learned activity management.

Of the remaining 22 studies only three were effective in reducing fatigue, and these interventions had a more general approach. These interventions were aimed at psychological distress, mood and physical symptoms, and varied strongly in duration and content.

Authors' conclusions

There is limited evidence that psychosocial interventions during cancer treatment are effective in reducing fatigue. At present, psychosocial interventions specifically for fatigue are a promising type of intervention. However, there is no solid evidence for the effectiveness of interventions not specific for fatigue. Most aspects of the included studies were heterogeneous, and therefore it could not be established which other types of interventions, or elements were essential in reducing fatigue.

Author(s)

Martine Margaretha Goedendorp, Marieke FM Gielissen, Constantijn AHHVM Verhagen, Gijs Bleijenberg

Abstract

Plain language summary

The effect of psychosocial interventions on fatigue during cancer treatment in adults

There is limited evidence that psychosocial interventions are effective in reducing fatigue during active treatment in cancer patients. Most promising are psychosocial interventions specifically designed to treat fatigue. In general, during these interventions patients were educated about fatigue, were taught in self‐care or coping techniques, and learned to manage their activity. Interventions that did not focus on fatigue were rarely effective in reducing fatigue.

Author(s)

Martine Margaretha Goedendorp, Marieke FM Gielissen, Constantijn AHHVM Verhagen, Gijs Bleijenberg

Reviewer's Conclusions

Authors' conclusions

Implications for practice

When cancer patients experience fatigue during cancer treatment there are several options to treat fatigue. In clinical practice an intervention with a general approach is usually chosen when intervening for fatigue, although at present there is no solid evidence for the effectiveness of psychosocial interventions not specific for fatigue. This review showed that interventions with a general approach were rarely effective in reducing fatigue, and these interventions focused on psychological distress, mood and physical symptoms. When other types of psychosocial intervention are offered to cancer patients, for example with the aim of reducing depression or pain, it is not likely that symptoms of fatigue automatically decrease with depression or pain.

The effectiveness of psychosocial interventions specifically designed to treat fatigue was significantly higher than interventions not specific for fatigue, and is currently the more promising type of intervention for reducing fatigue during cancer treatment. The interventions specific for fatigue contained, to a large extent, the same elements. In all interventions patients were: 1) educated about fatigue; 2) taught in self‐care or coping techniques; 3) taught activity management, learning to balance between activities and rest. However, currently with only a limited number of studies it could not be established which format or elements are essential to reduce fatigue during cancer treatment.

It is important to note that psychosocial interventions during active cancer treatment were the focus of this review. Our results are therefore not applicable to cancer patients who have completed their cancer treatment.

Implications for research

This review showed that there is limited support for psychosocial interventions for fatigue during cancer treatment. At present the effectiveness of psychosocial interventions specifically designed to treat fatigue is high, but there is no solid evidence for the effectiveness of psychosocial interventions not specific for fatigue.

As the RCTs were very heterogeneous in nature, and the number of psychosocial interventions specific for fatigue were limited, there are still some questions that need to be answered. First, it is important to know why some psychosocial interventions work, and therefore interventions should preferably be based on a theory or model. To find essential components that are necessary to reduce fatigue it is advisable to assess if factors that are expected to reduce fatigue also change during the intervention. In addition, the optimal duration of the intervention needs to be established, and the best method to provide the intervention. For example, it is unclear if telephone or face‐to‐face sessions are equally effective. Also there are no RCTs that evaluated the effectiveness of group interventions specific for fatigue.

As the included studies were very heterogeneous it was not possible to identify high risk groups. Thus, the question remains whether patients with specific malignancies, or patients receiving specific types of treatments are at risk of becoming more fatigued, although some studies point in that direction (Jereczek‐Fossa 2002). Some studies found that the prevalence of fatigue depended on the diagnosis. For example, patients with prostate carcinoma reported the least severe fatigue during radiotherapy and patients with lung, alimentary, and head and neck carcinoma reported the most severe fatigue (Hickok 2005a). Levels of fatigue also depended on diagnosis in patients receiving chemotherapy. In a group of cancer patients receiving cytotoxic treatment, lung and breast cancer patients experienced the highest degree of fatigue (Hartvig 2006).

There are also indications that the prevalence of fatigue depends on the type of treatment cancer patients receive. For example, breast cancer patients who had a mastectomy operation were more fatigued than women who underwent a lumpectomy. Receiving radiotherapy supplementary to chemotherapy led to an increase in fatigue in women with breast cancer (de Jong 2004).

In addition the course of fatigue appears to depend on the type of treatment cancer patients receive. For example, the course of fatigue in patients receiving chemotherapy seems to be different from the course of fatigue in patients receiving radiotherapy. After the start of chemotherapy the prevalence of fatigue increases, remaining stable during chemotherapy treatment (de Jong 2004; Jacobsen 1999). During radiotherapy the occurrence of fatigue increases with the number of weeks patients are treated with radiotherapy (Hickok 2005; Hickok 2005a).

If high risk groups can be identified it is important to know if these groups need adapted psychosocial interventions. In current guidelines for CRF, interventions for patients on active treatment are distinguished from interventions for patients at the end of life (NCCN 2008) although, the effectiveness of interventions specific for fatigue in this sample still needs to be demonstrated.

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