Telephone interventions for symptom management in adults with cancer
People with cancer experience a variety of symptoms as a result of their disease and the therapies involved in its management. Inadequate symptom management has implications for patient outcomes including functioning, psychological well‐being, and quality of life (QoL). Attempts to reduce the incidence and severity of cancer symptoms have involved the development and testing of psycho‐educational interventions to enhance patients' symptom self‐management. With the trend for care to be provided nearer patients' homes, telephone‐delivered psycho‐educational interventions have evolved to provide support for the management of a range of cancer symptoms. Early indications suggest that these can reduce symptom severity and distress through enhanced symptom self‐management.
To assess the effectiveness of telephone‐delivered interventions for reducing symptoms associated with cancer and its treatment. To determine which symptoms are most responsive to telephone interventions. To determine whether certain configurations (e.g. with/without additional support such as face‐to‐face, printed or electronic resources) and duration/frequency of intervention calls mediate observed cancer symptom outcome effects.
We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1); MEDLINE via OVID (1946 to January 2019); Embase via OVID (1980 to January 2019); (CINAHL) via Athens (1982 to January 2019); British Nursing Index (1984 to January 2019); and PsycINFO (1989 to January 2019). We searched conference proceedings to identify published abstracts, as well as SIGLE and trial registers for unpublished studies. We searched the reference lists of all included articles for additional relevant studies. Finally, we handsearched the following journals: Cancer, Journal of Clinical Oncology, Psycho‐oncology, Cancer Practice, Cancer Nursing, Oncology Nursing Forum, Journal of Pain and Symptom Management, and Palliative Medicine. We restricted our search to publications published in English.
We included randomised controlled trials (RCTs) and quasi‐RCTs that compared one or more telephone interventions with one other, or with other types of interventions (e.g. a face‐to‐face intervention) and/or usual care, with the stated aim of addressing any physical or psychological symptoms of cancer and its treatment, which recruited adults (over 18 years) with a clinical diagnosis of cancer, regardless of tumour type, stage of cancer, type of treatment, and time of recruitment (e.g. before, during, or after treatment).
Data collection and analysis
We used Cochrane methods for trial selection, data extraction and analysis. When possible, anxiety, depressive symptoms, fatigue, emotional distress, pain, uncertainty, sexually‐related and lung cancer symptoms as well as secondary outcomes are reported as standardised mean differences (SMDs) with 95% confidence intervals (CIs), and we presented a descriptive synthesis of study findings. We reported on findings according to symptoms addressed and intervention types (e.g. telephone only, telephone combined with other elements). As many studies included small samples, and because baseline scores for study outcomes often varied for intervention and control groups, we used change scores and associated standard deviations. The certainty of the evidence for each outcome was interpreted using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
Thirty‐two studies were eligible for inclusion; most had moderate risk of bias,often related to blinding. Collectively, researchers recruited 6250 people and studied interventions in people with a variety of cancer types and across the disease trajectory, although many participants had breast cancer or early‐stage cancer and/or were starting treatment. Studies measured symptoms of anxiety, depression, emotional distress, uncertainty, fatigue, and pain, as well as sexually‐related symptoms and general symptom intensity and/or distress.
Interventions were primarily delivered by nurses (n = 24), most of whom (n = 16) had a background in oncology, research, or psychiatry. Ten interventions were delivered solely by telephone; the rest combined telephone with additional elements (i.e. face‐to‐face consultations and digital/online/printed resources). The number of calls delivered ranged from 1 to 18; most interventions provided three or four calls.
Twenty‐one studies provided evidence on effectiveness of telephone‐delivered interventions and the majority appeared to reduce symptoms of depression compared to control. Nine studies contributed quantitative change scores (CSs) and associated standard deviation results (or these could be calculated). Likewise, many telephone interventions appeared effective when compared to control in reducing anxiety (16 studies; 5 contributed quantitative CS results); fatigue (9 studies; 6 contributed to quantitative CS results); and emotional distress (7 studies; 5 contributed quantitative CS results). Due to significant clinical heterogeneity with regards to interventions introduced, study participants recruited, and outcomes measured, meta‐analysis was not conducted.
For other symptoms (uncertainty, pain, sexually‐related symptoms, dyspnoea, and general symptom experience), evidence was limited; similarly meta‐analysis was not possible, and results from individual studies were largely conflicting, making conclusions about their management through telephone‐delivered interventions difficult to draw. Heterogeneity was considerable across all trials for all outcomes.
Overall, the certainty of evidence was very low for all outcomes in the review. Outcomes were all downgraded due to concerns about overall risk of bias profiles being frequently unclear, uncertainty in effect estimates and due to some inconsistencies in results and general heterogeneity.
Unsubstantiated evidence suggests that telephone interventions in some capacity may have a place in symptom management for adults with cancer. However, in the absence of reliable and homogeneous evidence, caution is needed in interpreting the narrative synthesis. Further, there were no clear patterns across studies regarding which forms of interventions (telephone alone versus augmented with other elements) are most effective. It is impossible to conclude with any certainty which forms of telephone intervention are most effective in managing the range of cancer‐related symptoms that people with cancer experience.
Telephone interventions provide a convenient way of supporting self‐management of cancer‐related symptoms for adults with cancer. These interventions are becoming more important with the shift of care closer to patients' homes, the need for resource/cost containment, and the potential for voluntary sector providers to deliver healthcare interventions. Some evidence supports the use of telephone‐delivered interventions for symptom management for adults with cancer; most evidence relates to four commonly experienced symptoms ‐ depression, anxiety, emotional distress, and fatigue. Some telephone‐delivered interventions were augmented by combining them with face‐to‐face meetings and provision of printed or digital materials. Review authors were unable to determine whether telephone alone or in combination with other elements provides optimal reduction in symptoms; it appears most likely that this will vary by symptom. It is noteworthy that, despite the potential for telephone interventions to deliver cost savings, none of the studies reviewed included any form of health economic evaluation.
Further robust and adequately reported trials are needed across all cancer‐related symptoms, as the certainty of evidence generated in studies within this review was very low, and reporting was of variable quality. Researchers must strive to reduce variability between studies in the future. Studies in this review are characterised by clinical and methodological diversity; the level of this diversity hindered comparison across studies. At the very least, efforts should be made to standardise outcome measures. Finally, studies were compromised by inclusion of small samples, inadequate concealment of group allocation, lack of observer blinding, and short length of follow‐up. Consequently, conclusions related to symptoms most amenable to management by telephone‐delivered interventions are tentative.
Emma Ream, Amanda Euesden Hughes, Anna Cox, Katy Skarparis, Alison Richardson, Vibe H Pedersen, Theresa Wiseman, Angus Forbes, Andrew Bryant
Plain language summary
Telephone interventions for managing symptoms in adults with cancer
Background-People with cancer experience a variety of symptoms caused by their disease and its treatment. Symptoms can include depression, anxiety, fatigue and pain. These are often managed, day‐to‐day, by patients or their family members. If symptoms are not well managed, this can lead to other problems, such as difficulties in carrying out everyday tasks, poor sleep and poor quality of life.
Cancer professionals have developed psychological and educational treatments to help people to manage cancer symptoms. These treatments (or interventions) can be delivered by telephone (telephone interventions) in the patients’ homes instead of face‐to‐face in hospital.
What questions does this review aim to answer?-This Cochrane Review aimed to answer the following questions.
1. Are telephone interventions for adults with cancer effective in relieving symptoms of cancer and cancer treatment?
2. Which symptoms are most reduced when telephone interventions are used?
3. What parts of telephone interventions have the most impact in reducing cancer symptoms?
In this review, telephone interventions were interventions given only, or mainly, by telephone. They were given by health professionals. As well as telephone contact, they could include face‐to‐face contact, or printed, digital or online information, such as, leaflets, computer programs and websites.
How did we answer these questions?-We searched medical databases and journals to find all randomised controlled trials that used a telephone intervention to reduce any cancer symptoms. Randomised controlled trials allocate people randomly to one treatment or another; they provide the most reliable evidence. Studies could compare telephone interventions with another telephone intervention, with another type of intervention (e.g. face‐to‐face), or with usual care. Participants in these studies were adults with any kind of cancer at any stage.
Results-We included 32 studies with a total of 6250 participants. Most studies (21) were from the USA. Nine studies recruited women with breast cancer, 11 included people with breast, colorectal, lung, or prostate cancer. Fourteen studies included people with early‐stage cancer. Nurses provided interventions in 24 studies. Only 10 studies delivered interventions solely by telephone, and 16 studies combined telephone calls with other materials (printed or digital). Studies measured symptoms of depression, anxiety, emotional distress, uncertainty, fatigue, pain, sexual symptoms, and breathlessness. They also measured the effect of all the symptoms together (the general symptom experience).
Most studies compared a telephone intervention with usual care alone or usual care with additional support. Eight studies compared two telephone interventions against each other; some also compared these with usual care.
Because the studies were so different from each other, we could not combine the results into one analysis for each symptom. However, some studies measured changes in symptoms using standardised or similar scales. They recorded participants’ scale scores at the beginning of the intervention, during the intervention, and at the end, resulting in a ‘change score’. We analysed the results from studies that recorded change scores.
What does evidence from the review tell us?-Twenty‐one studies provided evidence on depression compared to usual care or other interventions, but only nine provided change scores. These found that telephone interventions appeared to reduce symptoms of depression. Likewise, telephone interventions appeared effective compared to usual care or other interventions in reducing anxiety (16 studies; 5 contributed change scores); fatigue (9 studies; 6 contributed change scores); and emotional distress (7 studies; 5 contributed change scores).
Evidence for other symptoms was limited, making it difficult to draw conclusions.
Certainty of the evidence-Telephone interventions appear to relieve some symptoms of cancer and cancer treatment, however, the studies were small and very different from each other, so our confidence (certainty) in the evidence is very low. It is unclear whether telephone interventions alone, or combined with face‐to‐face meetings, or printed or audio materials, are most effective in reducing the many symptoms that people with cancer experience.
Conclusions-Telephone interventions are convenient for patients, their families and healthcare workers but the results of our review were not conclusive. Further, rigorous research on this topic would help to answer our review questions.
Search date-This review includes evidence published up to January 2019.
Emma Ream, Amanda Euesden Hughes, Anna Cox, Katy Skarparis, Alison Richardson, Vibe H Pedersen, Theresa Wiseman, Angus Forbes, Andrew Bryant
Implications for practice
This review found some evidence supporting use of telephone‐delivered interventions for managing cancer‐related symptoms ‐ most evidence is related to managing anxiety, depressive symptoms, emotional distress, or fatigue. This would suggest that telephone interventions should be considered as one component for managing these cancer‐related symptoms. Arguably, these interventions would not need to be provided within statutory services; they could be provided by voluntary sector providers, who frequently provide patients support and information via health professional‐delivered telephone help lines. We found limited evidence regarding potential management of some symptoms by telephone‐delivered intervention, notably regarding sexually‐related symptoms and pain.
Interventions evaluated in this review varied considerably in terms of (1) the number of calls provided; (2) the length and timing of calls; (3) the content of calls; and (4) provision or not of additional supportive material. It appears that for some symptoms (i.e. depressive symptoms), telephone‐only interventions may be indicated. However, given the small, mostly biased studies ‐ and lack of meta‐analysis ‐ this conclusion is tentative. For other symptoms, arguably those for which greater behaviour change may be required (e.g. fatigue), it may be the case that additional supportive materials are required to optimise outcomes. It has not been possible however through this review to conclude how many calls, delivered over what period, of particular duration and content, are required to generate effect. It appears that it may be beneficial for those delivering interventions to be trained in motivational interviewing skills.
It is noteworthy that most studies included within the review did not target samples with high baseline symptom burden. Arguably, it would be wise to do so, as there could be greater possibility for symptom reduction in such patient groups and greater associated cost savings.
Healthcare services are facing an unprecedented level of austerity that is likely to persist given ageing communities and finite health expenditure. There is a requirement for care to shift closer to home, and for cost containment to be applied. Telephone‐delivered interventions could make an important contribution to both requirements. Further research is needed to determine clearly which symptoms are most amenable to be managed through telephone‐delivered interventions, which patients should be targeted to achieve clinically important and sustained benefit, and which interventions are most cost‐effective.
There is risk of bias in the studies reported on in this review (most studies were at risk of some bias). When considered alongside other factors including between‐study heterogeneity and imprecise estimates of effect, the overall certainty of evidence is best considered very low, as we are very uncertain about the estimates. A lot of the heterogeneity was due to different cancer sites. Thus, the review findings need to be interpreted with a degree of caution. Consistency between this review and that of Chen 2018 is however encouraging and can lend support to the conclusions drawn.
Implications for research
Further work is necessary to determine:
- which cancer‐related symptoms are amenable to management by telephone‐delivered intervention; particular attention needs to be directed towards symptoms that have been subject to little research (e.g. sexually‐related symptoms, dyspnoea);
- what augmentation of telephone‐delivered interventions (e.g. with face‐to‐face meetings or additional resources) works, and in what particular circumstances;
- cost implications of delivering interventions by telephone to manage cancer‐related symptoms;
- consensus on the most appropriate measures to be used to measure outcomes and minimal clinically important differences for each one;
- consensus on standardising reporting of the intervention theory underpinning the intervention and its components;
- longevity of effects generated by telephone‐delivered interventions for cancer‐related symptoms;
- effectiveness of telephone‐delivered interventions in reducing fear of recurrence (a phenomenon that is increasingly being written about in the literature but is not deemed a symptom and thus was excluded from this review); and
- effectiveness of telephone‐delivered interventions for enhancing quality of life for people with cancer.
Future research is needed to address methodological limitations identified in the included studies. Notably, future randomised controlled trials need to have better methodological conduct and design to minimise risk of bias and to provide more extensive reporting of pertinent outcomes. Further, they need sufficient statistical power and length of follow‐up to generate much needed definitive evidence concerning efficacy of telephone‐delivered interventions for management of cancer symptoms across diverse patient groups.