Psychosocial interventions to improve quality of life and emotional wellbeing for recently diagnosed cancer patients
A cancer diagnosis may lead to significant psychological distress in up to 75% of cases. There is a lack of clarity about the most effective ways to address this psychological distress.
To assess the effects of psychosocial interventions to improve quality of life (QoL) and general psychological distress in the 12‐month phase following an initial cancer diagnosis.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4), MEDLINE, EMBASE, and PsycINFO up to January 2011. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies. Electronic searches were carried out across all primary sources of peer‐reviewed publications using detailed criteria. No language restrictions were imposed.
Randomised controlled trials of psychosocial interventions involving interpersonal dialogue between a 'trained helper' and individual newly diagnosed cancer patients were selected. Only trials measuring QoL and general psychological distress were included. Trials involving a combination of pharmacological therapy and interpersonal dialogue were excluded, as were trials involving couples, family members or group formats.
Data collection and analysis
Trial data were examined and selected by two authors in pairs with mediation from a third author where required. Where possible, outcome data were extracted for combining in a meta‐analyses. Continuous outcomes were compared using standardised mean differences and 95% confidence intervals, using a random‐effects model. The primary outcome, QoL, was examined in subgroups by outcome measurement, cancer site, theoretical basis for intervention, mode of delivery and discipline of trained helper. The secondary outcome, general psychological distress (including anxiety and depression), was examined according to specified outcome measures.
A total of 3309 records were identified, examined and the trials subjected to selection criteria; 30 trials were included in the review. No significant effects were observed for QoL at 6‐month follow up (in 9 studies, SMD 0.11; 95% CI ‐0.00 to 0.22); however, a small improvement in QoL was observed when QoL was measured using cancer‐specific measures (in 6 studies, SMD 0.16; 95% CI 0.02 to 0.30). General psychological distress as assessed by 'mood measures' improved also (in 8 studies, SMD ‐ 0.81; 95% CI ‐1.44 to ‐ 0.18), but no significant effect was observed when measures of depression or anxiety were used to assess distress (in 6 studies, depression SMD 0.12; 95% CI ‐0.07 to 0.31; in 4 studies, anxiety SMD 0.05; 95% CI ‐0.13 to 0.22). Psychoeducational and nurse‐delivered interventions that were administered face to face and by telephone with breast cancer patients produced small positive significant effects on QoL (in 2 studies, SMD 0.23; 95% CI 0.04 to 0.43).
The significant variation that was observed across participants, mode of delivery, discipline of 'trained helper' and intervention content makes it difficult to arrive at a firm conclusion regarding the effectiveness of psychosocial interventions for cancer patients. It can be tentatively concluded that nurse‐delivered interventions comprising information combined with supportive attention may have a beneficial impact on mood in an undifferentiated population of newly diagnosed cancer patients.
Karen Galway, Amanda Black, Marie M Cantwell, Chris R Cardwell, Moyra Mills, Michael Donnelly
Plain language summary
Individual therapy for people diagnosed with cancer
Cancer occurs in one in four of the population with over a quarter of a million people in the UK diagnosed each year (excluding non‐melanoma skin cancer). A diagnosis of cancer can be emotionally challenging. UK government policy recommends that all individuals who are diagnosed with cancer should be assessed for emotional problems and given access to appropriate psychological support services. However, the nature and content of services and their delivery is unclear. This review examines the effectiveness of individual psychosocial interventions in the first 12 months after diagnosis. The psychosocial interventions involve a 'trained helper' providing therapeutic dialogue, sometimes referred to as talking therapy, with an individual diagnosed with cancer with the aim of improving quality of life and emotional wellbeing. The review combines research data from 1249 people who took part in clinical trials to test psychosocial interventions. The results are inconclusive. No improvement in general quality of life was found, but small improvements in 'illness related' quality of life were observed. No improvements in anxiety or depression were found, but small improvements in mood were detected. Nurse‐led interventions using telephone and face‐to‐face delivery appear to show some promise. Future research should test assessment methods designed to identify patients who may benefit from psychosocial interventions, such as patients who are at risk of emotional problems; evaluate which type of 'trained helper' is the most appropriate professional to deliver psychosocial interventions for cancer patients; and conduct economic appraisals of the cost‐effectiveness of interventions.
Karen Galway, Amanda Black, Marie M Cantwell, Chris R Cardwell, Moyra Mills, Michael Donnelly
Implications for practice
The review suggests tentatively that nurse‐led interventions delivered in person or by telephone could provide valuable improvements in illness‐specific QoL and mood, as part of a package of cancer care. However, currently there is not enough evidence to support universal application for all patients. Risk screening is required to identify and target patients who are at most risk of emotional difficulties and, therefore, most in need of support, along with consideration of a range of possible intervention types to suit identified need. The use of tiered intervention approaches in response to strategic periodic risk screening to identify levels of need is recommended in the international guidelines for psycho‐oncology (Coleman 2011). Oncology teams may benefit from considering and assessing the economic and practical viability of formalising psychosocial support provision as part of the role of specialist cancer nurses within existing health service structures.
Implications for research
A key finding of the review is that existing comorbidity and risk assessment have not been robustly explored in the RCT context, making this an obvious next step in developing advanced research knowledge about appropriate services that can fulfil the existing NICE guidelines and emerging international psycho‐oncology practice guidelines for supporting cancer patients at the time of diagnosis.
Research trials identified for this review targeted patients according to cancer diagnosis alone, rather than primarily considering patients' perceived need for support. Randomised controlled trials testing psychosocial interventions that are targeted according to need in newly diagnosed cancer patients are lacking. It is necessary to improve the evidence based on need, that is, based on what works for people experiencing increased levels of distress. This approach would help to reduce the potential for measurement 'floor effects', in those who are not experiencing distress, to dilute the observed effects of psychosocial interventions.
The varied quality of reporting has led to difficulties identifying and classifying studies, due to the wide ranging variations in terminology that is used interchangeably in the field of psychosocial support. There is a need to agree upon common definitions of psychological distress and psychosocial interventions and impose the use of the conventions set out in the CONSORT statement (CONSORT 2010). Jacobsen and Jim have outlined a typology that could form the basis for consistency across future work on psychosocial interventions (Jacobsen 2008). Future studies should report on all validated measures in terms of summary measure results (rather than single subscales which are less valid and not directly comparable with summary scores).
In the fields of psychological, psychosocial and social care research it is particularly important that publishers remain mindful of the need for authors to provide results according to gender and age, given the documented gender differences seen in accessing psychosocial cancer support (Krizek 1999) and the general lack of gender‐specific or age‐specific results presented in the trials included in the present review (with the exception of intervention trials carried out with gender‐specific cancers such as breast cancer).
The measurement of outcomes is more complex in psychosocial research than in most drug‐based studies and clinical measures. However, the increasing number of publications of psychosocial interventions indicates this is an area of huge interest that is gaining increased support from funding bodies. A key feature of the RCT methodology design is the aspect of blinding, but a placebo cannot be effectively administered in trials of psychosocial interventions. Blinding outcome assessors would add to the rigour of the research in this field. Additional insights might be gained by generating synthesised qualitative accounts of the impact of interventions. The development of effective ways to combine mixed qualitative and quantitative data in systematic review terms is in its infancy (Hannes 2012). Future RCT work in this field should address more specific populations based on need; and provide high quality reporting standards.