To examine the effect of two interventions on emotion suppression and psychological distress in patients with non-metastatic breast cancer

Each group met for eight weeks for two hours each week. There were three groups: 

1. Supportive expressive intervention model: Adapted 52-week version down to brief protocol focused on social support and interpersonal relationships, emotional expression, life priorities, fear of death, and coping skills
2. Body-mind-spirit: Sessions focused on holistic health lifestyle, including physical activities and discussions; developing resilience, normalizing traumatic experiences, looking for mutual support, promoting self-acceptance, and peace of mind; mental well-being and forgiveness 
3. Control: Social support self-help without structured programming. Self-led group discussed healthy living (diet, food, exercise) and self-care; shared worries; showed mutual support

• N = 157 (BMS, n = 51; SEG, n = 49; control, n = 57)   
• AGE: Range = 18-65 years; mean = 47.7 years
• FEMALES: 100%
• CURRENT TREATMENT: Not applicable; completion of active treatment  
• KEY DISEASE CHARACTERISTICS: Non-metastatic breast cancer

• SITE: Multi-site   
• SETTING TYPE: Multiple settings    
• LOCATION: Hong Kong, China

PHASE OF CARE: Transition phase after active treatment

Three-arm RCT with measurement at baseline (T0), 4 months (T1), 8 months (T2), and 12 months (T3)

• Emotional suppression–Chinese Courtauld Emotional Control Scale (how often suppress anger, anxiety, and depression)
• Perceived stress–Chinese Perceived Stress Scale (how often felt stressful in past month)
• Anxiety and Depression–Chinese Hospital Anxiety and Depression Scale 
• Baseline psychological functioning–Chinese General Health Questionnaire (higher scores indicate worse health)

No difference in groups except for cancer duration, which was longer in SEG group and shorter in the BMS group (p = 0.01). There were no significant improvements in anxiety or depression. Emotion suppression: significantly decreased in the first four months for SEG and BMS with no change in control group. Perceived stress: No change in control or SEG but significant decreases in first four months in BMS group.
SEG resulted in moderate decrease in emotional suppression at 4 and 8 months, with participant perceived benefits; method is applicable for increased expression of emotions. SEG minimal effect on anxiety, depression and perceived stress. 
BMS showed no effect on anxiety and depression (d = 0.38–0.46) and little (small to medium  d = 0.07–0.2) effect on emotional suppression and perceived stress.

No significant effectiveness of the named therapies: SEG or BMS

• Small sample per group
• Risk of bias (no random assignment)
• Measurement/methods not well described
• Findings not generalizable
• Subject withdrawals ≥ 10%
• Other limitations/explanation: Drop-out rate. 11.5% overall; 10.2% in SEG group and 17.5% in control group.
• Low statistical power and low-moderate effect sizes. Unclear which aspects of the abbreviated 52-week protocol were applied. Self-selection bias may be at play. Treatment adherence was not measured; participants completed seven sessions on average.

Conduct large-scale research with sufficient power to examine effectiveness of these therapies. Learn and apply these therapeutic approaches. Use full-scale 52-week protocol for expression support therapy.

To evaluate the effectiveness of low light therapy (starlight therapy) on symptoms at end of life, including anxiety, agitation, dyspnea, restlessness, insomnia, and pain.

Patients observed or reporting symptoms were enrolled in the study and low light therapy (starlight therapy) was applied for two hours with observations at baseline, 30 minutes, and at two hours.

• N: 40
• AGE:  Average age = 82.25 years
• MALES: 65%
• FEMALES: 35%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Various terminal illnesses (cancer, dementia, neurologic disease, lung disease, heart disease) with prognosis of six months or less enrolled in hospice

• SITE: Multi-site   
• SETTING TYPE: Two inpatient hospice facilities, one community and one VA
• LOCATION: Southwest Ohio

• PHASE OF CARE: End-of-Life 
• APPLICATIONS: Palliative care

Prospective trial of use of low light therapy in patients observed or self-reporting symptoms

Lux meter (measuring light levels), vital signs, adapted Assessing Distressing Symptoms STAR Symptom Scale and Questionnaire, outcome measurement tools (physiological symptoms)

Respiratory rate significantly reduced from a rate of 23.91 at baseline to a mean rate of 18.63 (p < 0.01) at 30 minutes and a mean rate of 17.88 (p < 0.0001) at two hours. Heart rate also significantly reduced from a mean of 98.45 at baseline to a mean of 84.9 at 30 minutes (p < 0.01) and 84.55 at two hours (p < 0.0001). End-of-life symptoms as measured on the STAR symptom scale were noted and presence of moderate or severe symptoms were totaled with significantly fewer patients with presence of moderate or severe symptoms at both 30 minutes and two hours for agitation (p = 0.003 for 30 minutes, p < 0.0001 for two hours), anxiety (p < 0.0001 for 30 minutes, p < 0.0001 for two hours), restlessness (p < 0.001 for 30 minutes, p < 0.0001 for two hours), and sleep (p = 0.002 for 30 minutes, p < 0.0001 for two hours), with no significant reduction in numbers of patients with moderate or severe pain or dyspnea seen at any other time point.

Low light therapy shows some promise symptoms of agitation/anxiety/restless/sleep in patients with terminal illness in hospice, but further research needed given the small sample size, prospective design, limited patient population, and specific setting. 

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (sample characteristics)
• Measurement/methods not well described
• Findings not generalizable
• Other limitations/explanation: There seems a risk of selection bias and it was not clearly outlined how patients were chosen and there is a possibility that patients who were most likely to show benefit were disproportionately included. Tools used for measurement of symptoms were not provided, so evaluation was difficult. The impact of other interventions was difficult to evaluate, and it is noted that 7 of 40 patients received scheduled pain or sedation medication during therapy, but the medications are unknown and those patients were not broken out and analyzed separately.

An oncology nurse should be aware that noninvasive interventions such as low light therapy show promise for reductions in certain symptoms at end of life, but more research is warranted for recommendation for wider populations/settings.

To investigate the effect of intraoperative lidocaine infusion on postoperative cognitive function after craniotomy for supratentorial tumor resection

Patients in the experimental group received lidocaine (2%) as an IV bolus (1.5 mg/kg) after anesthesia induction followed by infusion at 2 mg/kg per hour throughout surgery (lidocaine group). Patients in the control group received normal saline at the same rate (normal saline group).

• N = 80   
• AGE: Mean = 44.5 years (SD = 9.5) (as calculated with the reported values from each group)
• MALES: 49%  
• FEMALES: 51%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Supratentorial brain tumor (e.g., glioma, meningioma) 
• OTHER KEY SAMPLE CHARACTERISTICS: 35% college or higher level of education. American Society of Anesthesiologists physical status I or II; body mass index (BMI) < 30; no history of systemic malignant tumors, diabetes, psychiatric disorders, or alcohol or drug abuse; ability to complete neuropsychological tests. To reduce the influence of potential preoperative cognitive dysfunction, patients with a preoperative Mini-Mental State Examination (MMSE) score < 24 or intracerebral vascular surgery were excluded.

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Academic hospital in China

PHASE OF CARE: Active anti-tumor treatment

Double-blind randomized controlled trial of lidocaine versus placebo with repeated measures

• Mini-Mental State Examination (MMSE)
• Information-Memory Concentration Test (IMCT)
• Hamilton Rating Scale for Depression (HRSD)
• Hamilton Rating Scale for Anxiety (HAMA)
• Outcome data were collected at six time points: before surgery, and at 24 hours, 1 week, 1 month, 3 months, and 6 months after surgery.

There were no significant demographic or clinical differences between the lidocaine group and normal saline group at baseline. Postoperative neuropsychological-cognitive decline was defined as a decline greater than or equal to the preoperative standard deviation on two or more of the four tests (MMSE, IMCT, HRSD, and HAMA). Using this criteria, there were a greater proportion of patients with postoperative decline in the saline group as compared to the lidocaine group at 1 week after surgery (40% versus 16%, p < 0.05), but this was not statistically significant after correcting for multiple comparisons. There were no significant differences between the groups in the incidence of postoperative cognitive decline at 1 day, 1 month, 3 months, or 6 months. Additional analyses using less stringent criteria for cognitive decline on MMSE and IMCT alone also did not reveal any differences.

Intraoperative lidocaine had no effect on cognitive functioning after supratentorial tumor resection.

• Small sample (< 100)
• Measurement validity/reliability questionable
• Intervention expensive, impractical, or training needs
• Questionable protocol fidelity
• Other limitations/explanation: Measures for anxiety (HAMA) and depressive symptoms (HAMD) were considered measures of neuropsychological functioning in this study; however, findings were unchanged in post-hoc analyses that excluded these measures. MMSE and IMCT are typically used as screening measures for dementia rather than as an outcome measure for subtle cognitive changes.

There is insufficient evidence to support the use of intraoperative lidocaine to reduce the incidence of cognitive decline after supratentorial tumor surgery.

To evaluate anxiety levels in patients with CML undergoing bone marrow biopsy who were exposed to the odor of C.aurantium essential oil versus those who were not

C. aurantium is an essential oil of the Citrus genus. In this study, participants were exposed to the essential oil odor via electronic diffuser. The study was divided into three groups. The first group received oral diazepam (10 mg), the second group was exposed to C. aurantium, and the third group was exposed to a placebo vaporized solution. In the second and third groups, exposure was 30 minutes long.

• N: 42   
• AGE: Adult average age of 45 (not further defined in article) 
• MALES (%): Not noted.   
• FEMALES (%): Not noted. 
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Adult patients with CML at any phase of the disease under regular treatment at research site.
• OTHER KEY SAMPLE CHARACTERISTICS: Both male and female patients with no history of psychiatric illness and a low level of anxiety at baseline were included. No other demographic data defined.

• SITE: Single site   
• SETTING TYPE: Not specified    
• LOCATION: Paraiba, Brazil

PHASE OF CARE: Multiple phases of care

Randomized controlled trial

State-Trait Anxiety Inventory (STAI) was used for subjective measurements. This is a self-reported anxiety scale. Physiological measurements including systolic and diastolic blood pressures, heart rate, and respiratory rate were also assessed.

The groups that received diazepam and exposure to C. aurantium both showed significant decrease in systolic blood pressure (p < 0.05). The group exposed to C. aurantium experienced significant decrease in heart rate (p < 0.001) as well as significant differences in anxiety levels as reported on the STAI-S before and after the treatment when analyzed by Wilcoxon test (p < 0.001).

Findings suggest that C. aurantium may potentiate anxiolytic effects in patients with CML undergoing bone marrow biopsy.

• Small sample (< 100)
• Risk of bias (sample characteristics)
• Key sample group differences that could influence results
• Measurement/methods not well described
• Findings not generalizable
• Other limitations/explanation: Patient demographics not fully defined; limited to patients with CML; methods could be defined in much better detail.

C. aurantium and other anxiolytic essential oils may be considered as nonpharmacologic tools for the reduction of anxiety in patients with cancer, although much more research is needed in more diverse patient populations.

To examine effects of routine distress screening and referral on patient’s mood, satisfaction, and quality of life

Patients were randomized to receive the routine screening or usual care. Study assessment were done at outpatient visits weeks 1, 7, 13, and 25 after study entry. Usual care involved medical care and psychosocial care by the physician; psychosocial care was not integrated and referrals for psychosocial care were based on physician judgment. There was no structural distress screening. In the screening group, patients completed the Distress Thermometer and Problem List at each clinic visit. For scores of 4 or greater, patients were offered referral to an appropriate provider.

• N = 195 entered, 111 at 25 weeks 
• AGE: Mean = 61.6 years
• MALES: 42.8%  
• FEMALES: 48.2%
• KEY DISEASE CHARACTERISTICS: Newly diagnosed with lung cancer, prior to treatment
• OTHER KEY SAMPLE CHARACTERISTICS: The majority had stage IV disease. Baseline scores did not show clinically relevant anxiety or depression

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Netherlands

PHASE OF CARE: Active anti-tumor treatment

RCT

• EORTC-QLQ-C30: Quality of life
• EORTC-LC13: Symptoms specific to lung cancer
• Hospital Anxiety and Depression Scale (HADS)
• PSQIII: Depression
• Charlston Comorbidity Index

There were no differences between groups in study outcome results for quality of life, depression, or anxiety. There were no differences in hospitalizations or ED visits between groups.

Findings did not show that routine distress screening and provision of care based on screening had any effect.

• Risk of bias (no blinding)
• Subject withdrawals ≥ 10%  
• Other limitations/explanation: Use of referrals in both study groups is not discussed and results of distress screening are not provided.

This study did not show any significant differences in patient outcomes due to implementation of routine distress screening and associated supportive care referral.

STUDY PURPOSE: To synthesize published research to assess if yoga improves physical and psychosocial quality of life in patients receiving treatment for breast cancer.

TYPE OF STUDY: Systematic review

DATABASES USED: Scopus, Medline, PubMed, Science Direct, Cochrane, ProQuest

YEARS INCLUDED: (Overall for all databases) January 2009 to July 2014

INCLUSION CRITERIA: Articles with a yoga or mindfulness-based stress reduction (MBSR) intervention that reported outcomes related to physical or psychosocial quality of life in patients with breast cancer; studies with 15 or more participants were included. 

EXCLUSION CRITERIA: Articles that were duplicate, inaccessible, or with irrelevant records.

TOTAL REFERENCES RETRIEVED: 395

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Blinded/duplicated two-stage screening approach to select appropriate articles; critical review and article scoring was independently done by two researchers

FINAL NUMBER STUDIES INCLUDED: 38

TOTAL PATIENTS INCLUDED IN REVIEW: Not reported

SAMPLE RANGE ACROSS STUDIES: RCTs: 18 to 410; NRTs: 15 to 286; otherwise not noted 

KEY SAMPLE CHARACTERISTICS: RCTs: average age was 58.3 years; NRTs: average age was 50.3 years; all participants in all studies were women except for nine men included in one study; all studies look at patients with breast cancer though further details were not specified (exact phase/type of treatment, etc.)

PHASE OF CARE: Not specified or not applicable; details about each study’s participants not specified

As relevant to this PEP topic: 60% (3 of 5) studies that examined anxiety supported decreased general anxiety among patients who participated in yoga therapy. The other two large studies also showed less anxiety in this population, although it was divided into state and trait anxiety. A decrease in depression and depressive symptoms was reported in all of the studies reviewed that looked at psychosocial benefits related to yoga, which supports other meta-analyses stating that adding yoga therapy to traditional breast cancer treatment can decrease depression in these patients.

Evidence supports that yoga can have benefits on both physical and psychosocial quality of life in patients with breast cancer, including a decrease in both anxiety and depression. Additional research should aim to assess long-term effects of yoga in this population.

• Low sample sizes
• No meta-analysis, no table of evidence; difficult to synthesize all data accurately independently on article review

Yoga is an evidence-based intervention that may reduce anxiety and depression in patients with cancer. Recommending yoga to patients with breast cancer undergoing active treatment may be beneficial, particularly for those with high levels of anxiety and/or depression.

STUDY PURPOSE: To review results of yoga trials conducted among patients during cancer treatment

TYPE OF STUDY: Systematic review

DATABASES USED: MEDLINE, CINAHL, and PsycINFO through October 2015

INCLUSION CRITERIA: Children or adults undergoing cancer treatment, intervention was yoga or a component of yoga, randomized or non-randomized study

EXCLUSION CRITERIA: Patients receiving only hormone therapy, interventions involving only meditation or yoga, delivered as part of an MBSR intervention

TOTAL REFERENCES RETRIEVED: Not reported

FINAL NUMBER OF STUDIES INCLUDED: 4 studies of children, 22 total studies–13 were RCTs

TOTAL PATIENTS INCLUDED IN REVIEW: 1,046

SAMPLE RANGE ACROSS STUDIES: 4 to 164

KEY SAMPLE CHARACTERISTICS: Varied tumor types–majority were done in women with breast cancer. Treatments include chemotherapy, radiation, surgery and combination of these

PHASE OF CARE: Active anti-tumor treatment     

APPLICATIONS: Pediatrics

Doses of yoga ranged from 1 to 18 sessions and frequency ranged from every three weeks to three times per week. Some were delivered as group classes and two included caregivers. Some interventions included psychoeducation and supportive interventions. Some provided instructions and recommendations for practice at home. Attrition rates ranged from 8%-56%. Adherence to planned sessions ranged from 59%-88% and where measured, adherence to home practice ranged from 50%-80%. In non-random studies, improvements in anxiety, depression, mood, cognition, sleep, and fatigue were reported. Several RCTs reported improvement in distress, depression, anxiety, and multiple treatment-related side effects and symptoms.

Evidence suggests that yoga can be helpful to adults undergoing cancer treatment. There is insufficient evidence to draw any conclusions regarding benefit for children.

• No quality evaluation
• Mostly low quality/high risk of bias studies
• Low sample sizes
• Varied type, frequency, and duration of interventions. Multiple limitations in study designs and high attrition rates

There is not a lot of strong evidence to show benefits of yoga for various symptoms for patients during cancer treatments due to individual study design limitations. Existing evidence suggests that yoga may be helpful for anxiety, depression, sleep, and cognitive impairment. Further well-designed research to explore these areas is needed. Yoga is a relatively low-risk intervention that may be helpful and could be suggested to patients who are interested and able to participate.

STUDY PURPOSE: To assess effects of yoga on health-related quality of life, mental health, and cancer-related symptoms among women with a diagnosis of breast cancer who are receiving active treatment or have completed treatment.

TYPE OF STUDY: Systematic review

DATABASES USED: Cochrane Breast Cancer Specialised Register, MEDLINE (via PubMed), Embase, the Cochrane Central Register of Controlled Trials (2016, Issue 1), Indexing of Indian Medical Journals, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov 

YEARS INCLUDED: (Overall for all databases) did not give date range

INCLUSION CRITERIA: RCTs were eligible if they compared yoga interventions versus no therapy or versus any other active therapy in women with a diagnosis of non-metastatic or metastatic breast cancer, and if they assessed at least one of the primary outcomes on a patient-reported instrument, including depression, anxiety, fatigue, or sleep-disturbances.  

EXCLUSION CRITERIA: Duplicates, not including randomized control methodology, no assessment of relevant outcomes.

TOTAL REFERENCES RETRIEVED: 432

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Blinded/duplicated two-stage screening approach to select appropriate articles; critical review and article scoring was independently done by two researchers

FINAL NUMBER STUDIES INCLUDED: 23

TOTAL PATIENTS INCLUDED IN REVIEW: 2,166

SAMPLE RANGE ACROSS STUDIES: Only RCTs included.  

KEY SAMPLE CHARACTERISTICS: Sample sizes ranged from 18 to 309, with median of 74.5. Women's mean age ranged from 44 to 62.9 years, with a median of 54 years. All studies included women with non-metastatic breast cancer; one study included women with metastatic disease. Women included were at different stages in both their diagnosis and treatment. Cancer treatment type was varied.

PHASE OF CARE: Not specified or not applicable; details about each study’s participants not specified

APPLICATIONS: Elder care, palliative care

As relevant to these PEP topics, yoga primarily improved health-related quality of life, fatigue, and sleep disturbances. Evidence suggests short-term effects of yoga compared with psychosocial/education interventions on depression, anxiety, and fatigue. During active cancer treatment, yoga improved depression, anxiety, and fatigue compared with no therapy or psychosocial/educational interventions. After therapy, yoga showed effects on health-related quality of life, fatigue, and sleep disturbances. The studies were not robust enough to measure effects of yoga more than five years after diagnosis or in the metastatic breast cancer population.

Evidence supports that yoga can have benefits on health-related quality of life in patients with breast cancer, including a decrease in anxiety, depression, and fatigue. Additional research is needed to assess the effectiveness of yoga more than five years from diagnosis and in the metastatic population.

Yoga has been shown to be an evidence-based intervention which can improve health-related quality of life and symptoms, including depression, anxiety, and fatigue, in women with non-metastatic breast cancer at all stages of treatment, up to five years postdiagnosis.

To evaluate differences in psychological states between breast cancer survivors who do practice yoga and those who do not

This case-control exploratory study consisted of two groups. The first was breast cancer survivors doing regular yoga (more than six months of regular yoga practice in the last year), and the second was women who had no prior yoga experience (or less than three yoga sessions in the last year). Yoga experience was self-reported by the participants, including their regular yoga schedule. No changes to their yoga practice or schedule were made by the researchers.

• N = 52   
• AGE: 30-65
• FEMALES: 100%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Female breast cancer survivors diagnosed with stage II or III ILC or IDC who received adjuvant chemotherapy and completed all treatment at least six months prior. 
• OTHER KEY SAMPLE CHARACTERISTICS: Patients with neutropenia, grade 3 or 4 thrombocytopenia, and other reported chronic illnesses (diabetes, arthritis, hypertension, thyroid abnormalities, obesity, or recent acute infections) were excluded. Patients who participated in other complementary or alternative treatments within the past six months were also excluded.

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: Participants were screened at six-month follow-up appointment at three cancer centers in Bengaluru, India.

PHASE OF CARE: Late effects and survivorship

Case-control exploratory study

Perceived stress scale, Spielberg’s state and trait anxiety questionnaire, Beck’s depression inventory, General Health Questionnaire, WHO QOL Questionnaire-BREF

Analysis revealed significantly decreased anxiety, depression, and stress in the group that participated in yoga (p < 0.001). This group also reported better general health and overall quality of life (p < 0.001). Higher income predicted lower anxiety and depression scores, while better reported sleep quality predicted lower stress and depression scores as well.

This study supports yoga as an intervention to decrease anxiety, depression, and stress in breast cancer survivors.

• Small sample (< 100)
• Risk of bias (no appropriate attentional control condition)
• Findings not generalizable
• Other limitations/explanation: Differences in regular yoga practices among the participants could have influenced the results as yoga schedules were not controlled for. In addition, this study only looks at yoga in breast cancer survivors and may not be generalizable to other patients with cancer.

Yoga is an evidence-based intervention that may reduce anxiety and depression in patients with cancer. Although this study only examined breast cancer survivors, discussing yoga as a method to decrease anxiety and depression may be an appropriate option for many patients with cancer.

STUDY PURPOSE: To identify core components of self-management education interventions and assess effectiveness

TYPE OF STUDY: Systematic review

DATABASES USED: Ovid, MEDLINE, EMBASE, Cochrane collaboration, CINAHL, PsycINFO

INCLUSION CRITERIA: Adults, use of any type of teaching strategy, addressed any single core element of self-management interventions as defined by the authors, group based or individual structure

EXCLUSION CRITERIA: Psychotherapy or support groups, use of only information such as leaflets or videos, focus on family members, focus on decision making by patients, gray literature, interventions related to diet and exercise

TOTAL REFERENCES RETRIEVED: 4,579

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane risk of bias tool to evaluate study quality. All were at high risk of bias related to lack of blinding

FINAL NUMBER STUDIES INCLUDED: 43 

TOTAL PATIENTS INCLUDED IN REVIEW: 6,795

SAMPLE RANGE ACROSS STUDIES: 22 to 483

PHASE OF CARE: Multiple phases of care

Authors attempted to correlate core elements of interventions with outcomes. Overall, there were very few studies that had any common combinations of core elements, so this analysis could not be done. Overall, studies suggested that psychoeducational interventions may be beneficial for relieving symptoms of anxiety and depression. The content, elements, structure duration and frequency of interventions across studies were varied. Many interventions labeled as self-management education did not include components related to self management.

Psychoeducational interventions appear to be beneficial for symptoms of anxiety and depression. It is not possible to determine the specific components of these types of interventions that are most helpful.

• Mostly low quality/high risk of bias studies
• High heterogeneity
• Wide variation of the components, etc., of these types of interventions

Psychoeducational interventions of various types can be beneficial in reducing patients’ anxiety and depressive symptoms.