GENERAL AND SUPPORTIVE CARECharacteristics and methodological quality of 25 years of research investigating psychosocial interventions for cancer patients
Introduction
At most recent report, more than 11 million Americans were living with cancer.1 Cancer’s diagnosis, treatment, and aftermath present challenges that can contribute to psychological morbidity and can compromise quality of life. Diagnosis involves many stressors and can provoke worries about functioning, social value, finances, burden on one’s family, and death.[2], [3] Cancer treatments produce side effects, such as fatigue, nausea, and changes in appearance and functioning that can be difficult to cope with.[4], [5], [6], [7] After treatment is complete, stressors involve continued medical follow-up; residual physical, interpersonal psychological, and spiritual effects; and practical issues, such as employment, finances, and insurance coverage.8 If cancer progresses despite treatment, worries about the future predominate.9 Late-stage cancer brings existential concerns10 and potentially pain.11 With the recognition of such difficulties, attention in recent decades has been directed at developing and testing interventions to improve the quality of life of individuals coping with cancer.12
Quality of life is subjective and multidimensional. Seven dimensions affected by cancer and its treatment are: (1) physical concerns, (2) functional ability, (3) family well-being, (4) emotional well-being, (5) treatment satisfaction, (6) sexuality and intimacy, and (7) social functioning.13 Accordingly, interventions aimed to improve the quality of life for individuals diagnosed with cancer are diverse and often feature multiple potentially therapeutic components targeted at multiple outcomes.[2], [14] Some types resemble common psychotherapeutic approaches, such as group cognitive behavioral therapy,[15], [16] problem-solving therapy,17 and psychodynamic psychotherapy.18 However, various other approaches also have been tested. Some examples include: written expressive disclosure,19 nurse-administered self-care self-efficacy enhancement,20 complementary and alternative medicine support,21 movement and dance,22 and audiotaped side effect management education.23 Similarly, the range of outcome variables assessed in studies evaluating such interventions (e.g. depression, anxiety, body image, pain, fatigue, fear of recurrence, levels of perceived social support, sexual functioning, marital satisfaction, sleep disruption) reflects this multidimensionality in the conceptualization of quality of life.
Given the now considerable amount of research examining psychosocial interventions for cancer,24 it is important to examine its scope and quality. Such an evaluation can characterize this literature, analyze trends over time, and identify directions for improvement. A comprehensive review also is useful in understanding what types of individuals, with what types of cancers, exposed to what types of psychosocial interventions have been subjected to empirical scrutiny. This can identify understudied populations and determine to what extent available resources for cancer patients have been evaluated.
Attention to methodological quality is also important. In prior reviews, the quality of investigations studying psychological therapies for cancer patients was deemed suboptimal. In Newell et al.’s evaluation of 155 randomized, controlled trials of psychological therapies for adult and child cancer patients, the median quality score was less than one-third of the maximum number of points possible.25 The authors noted that this was likely related to poor reporting of methods. In Rehse and Pukrop’s26 review of 37 published controlled studies investigating psychosocial interventions’ effect on quality of life, studies scoring lower in methodological quality had smaller outcome effect sizes.
Studies of psychosocial interventions for cancer patients have been criticized for narrow inclusion criteria and for being too intensive to allow participation of those most in need27 but such criticisms need to be empirically validated.28 Some investigators have pointed out the dearth of non-European American samples and the typical low statistical power of research in this area.29 Other research has noted the high levels of dropout associated with psychosocial interventions for cancer patients.[30], [31] Such methodological shortcomings may bias estimates of treatment efficacy.[26], [32] Closer attention to methodology and its impact, such as on participation rates, would help direct future inquiry, intervention development, and approaches to improve methodology.
A number of high-quality reviews and meta-analyses have investigated the efficacy of psychosocial interventions for cancer patients. For example, Meyer and Mark33 conducted a meta-analysis of 45 randomized, controlled studies of psychosocial interventions with adult cancer patients published between 1979 and 1993; Devine and Westlake34 reviewed 116 studies reported between 1976 and 1993 examining psycho-educational care for cancer patients; Newell and colleagues 25 reviewed randomized, controlled trials published between 1980 and 1998 evaluating the effectiveness of a psychosocial interventions aimed at improving cancer patients’ psychosocial, side effect, immune, or survival outcomes. In addition to reviews selecting studies with particular types of designs or levels of quality, more focused reviews have concentrated on patients with particular types of cancer, such as breast,35or stages of cancer, such as advanced,36 particular outcomes, such as fatigue,37 depression and anxiety,[38], [39] or survival,[40], [41] or particular types of interventions, such as physical activity,42 or guided imagery.43
Previous reviews and meta-analyses predominantly have focused on evaluating the extent to which evidence supports interventions’ efficacy. Methodological and reporting limitations often have led to studies being excluded from these reviews.25 By contrast, rather than summarizing outcomes, the purpose of the present review was to characterize the evolving nature and scope of psychosocial cancer intervention research as a whole, with as few exclusions as possible. We therefore conducted a comprehensive synthesis of 25 years of published reports and unpublished dissertations evaluating psychosocial interventions designed to improve the quality of life of cancer patients. We analyzed characteristics of the reports, the participants, the treatments investigated and their delivery, the outcomes assessed, the methodological quality of these studies, and challenges noted by investigators conducting this research. We also examined trends over time in the amount of research being conducted and its methodological quality.
Section snippets
Study identification
Studies included in the review examined psychosocial interventions for adult cancer patients that: (1) reported outcomes on psychological, emotional, behavioral, physiological, functional, or medical status; (2) were first reported as a published article or an unpublished dissertation between January 1980 and December 2005; and (3) included 10 or more individuals per group. Studies examining interventions aimed at increasing adherence to anti-cancer treatment and focusing exclusively on
Study, investigator, report, and sample characteristics
There was a dramatic increase in the number of studies conducted over the 25 year period, from an average of 10 projects per year appearing in the 1980s, to 22 per year from 1995 to 1999, to 36 per year from 2000 to 2005. The majority of principal investigators was affiliated with a university (75.3%), held a Ph.D. (66.8%), and was female (59.85). The projects most often were funded by private foundations (40.4%) and federal agencies (34.3%), but a fairly high proportion (36.3%) did not report
Discussion
This overview reveals the topography of the field of psychosocial intervention studies for adult cancer patients conducted over two-and-a-half decades. Research in this area increased dramatically, reflecting enthusiasm and support for providing empirically-based assistance and tools for individuals coping with cancer’s diagnosis, treatment, and survivorship. This conclusion concurs with that of a recent Institute of Medicine (IOM) Report which asserted there is a “wealth” of psychosocial
Conclusion
This comprehensive characterization of the literature investigating psychosocial interventions for cancer patients documented its dramatic growth, and its wide scope with respect to treatment approaches, target difficulties, and types of patients. Because of the disconnects between interventions that are reported on in the research literature and the services that are sought by, and available to, cancer patients, and discrepancy between the characteristics of research participants and the
Conflict of interest
I assert that I do not, nor do my coauthors, have any financial and personal relationships with other people or organisations that could inappropriately influence (bias) this research that would represent a conflict of interest.
Acknowledgements
This work was supported by a grant from the National Cancer Institute (R01 CA100810) to Anne Moyer. We are grateful to John W. Finney for comments on an earlier draft of this manuscript.
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