Multidimensional rehabilitation programmes for adult cancer survivors Edited (no change to conclusions)

Abstract

Background

Multidimensional rehabilitation programmes (MDRPs) have developed in response to the growing number of people living with and surviving cancer. MDRPs comprise a physical component and a psychosocial component. Studies of the effectiveness of these programmes have not been reviewed and synthesised.

Objectives

To conduct a systematic review of studies examining the effectiveness of MDRPs in terms of maintaining or improving the physical and psychosocial well‐being of adult cancer survivors.

Search methods

We conducted electronic searches in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL and PsychINFO up to February 2012.

Selection criteria

Selection criteria focused on randomised controlled trials (RCTs) of multidimensional interventions for adult cancer survivors. Interventions had to include a physical component and a psychosocial component and to have been carried out on two or more occasions following completion of primary cancer treatment. Outcomes had to be assessed using validated measures of physical health and psychosocial well‐being. Non‐English language papers were included.

Data collection and analysis

Pairs of review authors independently selected trials, rated their methodological quality and extracted relevant data. Although meta‐analyses of primary and secondary endpoints were planned there was a high level of study heterogeneity and only one common outcome measure (SF‐36) could be statistically synthesised. In addition, we conducted a narrative analysis of interventions, particularly in terms of inspecting and identifying intervention components, grouping or categorising interventions and examining potential common links and outcomes.

Main results

Twelve RCTs (comprising 1669 participants) met the eligibility criteria. We judged five studies to have a moderate risk of bias and assessed the remaining seven as having a high risk of bias. It was possible to include SF‐36 physical health component scores from five studies in a meta‐analysis. Participating in a MDRP was associated with an increase in SF‐36 physical health component scores (mean difference (MD) 2.22, 95% confidence interval (CI) 0.12 to 4.31, P = 0.04). The findings from the narrative analysis suggested that MDRPs with a single domain or outcome focus appeared to be more successful than programmes with multiple aims. In addition, programmes that comprised participants with different types of cancer compared to cancer site‐specific programmes were more likely to show positive improvements in physical outcomes. The most effective mode of service delivery appeared to be face‐to‐face contact supplemented with at least one follow‐up telephone call. There was no evidence to indicate that MDRPs which lasted longer than six months improved outcomes beyond the level attained at six months. In addition, there was no evidence to suggest that services were more effective if they were delivered by a particular type of health professional.

Authors' conclusions

There is some evidence to support the effectiveness of brief, focused MDRPs for cancer survivors. Rigorous and methodologically sound clinical trials that include an economic analysis are required.

Author(s)

David A Scott, Moyra Mills, Amanda Black, Marie Cantwell, Anna Campbell, Chris R Cardwell, Sam Porter, Michael Donnelly

Abstract

Plain language summary

Multidimensional rehabilitation programmes for adult cancer survivors 

Due to improvements in detection, treatment and care an increasing number of patients are living with or surviving cancer. However, patients who survive cancer may experience a range of physical and emotional symptoms which impact on their health and quality of life. Physical symptoms may include fatigue, reduced muscle strength and weight gain, while emotional symptoms may include, for example, anxiety and depression. Rehabilitation programmes have been developed to address these symptoms and problems and to help survivors have a better quality of life. Some rehabilitation programmes attempt to help people overcome difficulties associated with either physical or emotional symptoms whilst other programmes ‐ multidimensional rehabilitation programmes (MDRPs) ‐ try to address physical and emotional symptoms together. This review has collected and examined the best available research to assess the nature and degree to which MDRPs reduce physical and emotional problems and improve the health‐related quality of life of adult cancer survivors.

We identified 12 studies which were suitable for use in the review. However, each study had some problems in the way that it was carried out. These problems make it difficult to be certain about the usefulness of MDRPs. Overall, the reviewed articles suggest that MDRPs are more likely to help patients cope with their physical needs than their emotional needs. MDRPs which looked at one specific behaviour area, such as diet, physical activity or stress, appeared to be more helpful for patients than programmes which attempted to address several different behaviours. Successful MDRPs usually involved face‐to‐face contact between a patient and a health professional (usually a nurse or physical therapist) and included at least one follow‐up phone call. Programmes which took place over longer time periods (more than six months), or which were delivered by a specific type of health professional, or were delivered to a single cancer site were not more successful than brief, focused MDRPs delivered to mixed groups of cancer patients.

Author(s)

David A Scott, Moyra Mills, Amanda Black, Marie Cantwell, Anna Campbell, Chris R Cardwell, Sam Porter, Michael Donnelly

Reviewer's Conclusions

Authors' conclusions 

Implications for practice 

Multidimensional rehabilitation programmes (MDRPs) are complex and multi‐faceted interventions and due to the small body of research evidence currently available, practice recommendations are limited. Tentatively, this review suggests that MDRPs may have positive physical benefits for adult cancer survivors. In particular, programmes with a uni‐dimensional focus appear to be more successful in terms of generating a positive change in the area related to their focus. Cancer site‐specific programmes do not have any advantage over programmes designed for participants with mixed cancer diagnoses. Available evidence suggests that face‐to‐face delivery, supplemented with at least one follow‐up telephone call, may be the most effective mode of intervention delivery. There is no evidence to support the development of rehabilitation programmes conducted over prolonged periods or with multiple contacts; there is no evidence to suggest a difference in outcome depending on the type of health professional delivering the intervention. Urging caution about the findings, service providers may benefit from giving attention to the development of short, focused rehabilitation programmes or sessions that patients could choose based on the match or 'fit' with their specific needs.

Implications for research 

Due to the small number of high‐quality studies in this area, the main lessons from this review relate to the need for future research in this area. There is a need for further large randomised controlled trials (RCTs) to test the effectiveness of MDRPs in clinical practice. RCTs control for unknown confounding factors of which there are many in rehabilitation (Turner‐Stokes 2005). Studies should include power calculations to ensure adequate sample sizes and strategies to allow for attrition and to ensure recruitment targets are achieved. In addition, assessor blinding should be incorporated and there is a need for uniformity in outcome measures that will facilitate meta‐analyses. It would be beneficial to use validated methods to assess physical functioning outcomes using either exercise tests or pedometers/accelerometers instead of self reported physical activity. Due to the tightening financial constraints currently being faced by many healthcare systems, there is an overwhelming need to identify the cost‐benefits of new interventions over conventional care for survivors.

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