To evaluate the effectiveness of a psychoeducational program on cancer-related fatigue

Patients were randomly assigned to the study intervention or usual care. Patients in the intervention group (PEPs) received written information explaining cancer-related fatigue and difference approaches for management. Patients in this group were also encouraged to participate in five group educational sessions of two hours each over a six-week period. The PEPs content was designed to incorporate NCI and CPEN guidelines. Content included information about the disease, fatigue, self expression of attitude, coping strategies, and skill development for managing fatigue. Educational teams received a two-day intensive training to standardize program content. Patients in the control group received the written documentation as described. After the study, patients in the control group were offered participation in the program.

• N = 129   
• AGE: Mean = 55.9 years
• MALES: 15.6%  
• FEMALES: 84.4%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Multiple tumor types–over 60% were breast cancer cases. Average of slightly less than one month since diagnosis.
• OTHER KEY SAMPLE CHARACTERISTICS: Mean baseline fatigue was 5 in both groups.

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: France

RCT

• Numeric rating scale for fatigue intensity
• FACT-Fatigue
• Piper Fatigue Scale
• EORTC-QLQ-C30
• Hospital Anxiety and Depression Scale

There were no differences between groups in fatigue scores after the intervention, and no differences in the trajectory of fatigue. Fatigue declined overall in all patients. There were no differences between groups in anxiety or depression.

The educational program tested here did not demonstrate an effect on fatigue, anxiety, or depression.

• Risk of bias (no appropriate attentional control condition)
• Questionable protocol fidelity
• Subject withdrawals ≥ 10%
• Other limitations/explanation: Authors questioned the possibility of study group contamination since all patients were treated at the same clinical centers. No observations to check program fidelity were described. Phase of care is not clear in this report. Question of author bias–authors attribute lack of apparent effect to the need for better fatigue measures.

Psychoeducation is an intervention that has shown mixed results for impact on cancer-related fatigue and other symptoms. The specific program tested here did not demonstrate an effect. Fatigue in particular is a complex multifaceted symptom. Various psychoeducational and supportive approaches have also been complex in terms of design, content, timing, dose, etc. The effectiveness of psychoeducational-type interventions may relate to all of these aspects of both content and delivery.

To assess the impact of palliative care interventions on symptoms and quality of life among patients undergoing HCT

Within 72 hours of transplant admission, patients were randomized to treatment and control groups. Within 72 hours of group assignment, patients in the palliative care group met with the palliative care physician or advanced practice nurse for planning management of symptoms. Palliative interventions were provided according to guidelines in a manual developed for addressing pharmacologic and non-pharmacologic symptom management interventions. Study measures were obtained at baseline and during the second week of hospitalization, day 5 after autologous cell infusion, day 8 after allogeneic HCT, and at 3 and 6 months after HCT.

• N = 157    
• AGE: Mean = 57.05 years
• MALES: 42%  
• FEMALES: 58%
• CURRENT TREATMENT: Combination radiation and chemotherapy
• KEY DISEASE CHARACTERISTICS: Most had autologous HCT
• OTHER KEY SAMPLE CHARACTERISTICS: Most had college or more formal education. More than 70% were married.

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Massachusetts

• PHASE OF CARE: Transition phase after active treatment
• APPLICATIONS: Palliative care

RCT

• FACT-BMT
• FACT Fatigue score
• PHQ9 for depression
• Hospital Anxiety and Depression Scale
• Edmonton Symptom Assessment Scale (ESAS)

Hospitalization lasted an average of 21 days, ranging from 12-102.  Most commonly addressed symptoms were nausea, pain, diarrhea, and constipation. At two weeks, BMT scores (p = 0.02), fatigue scores (p = 0.04) ESAS symptoms burden scores (p = 0.02), and HADs anxiety and depression subscales (p < 0.008) were all better in the palliative care group. At three months, depression scores were lower in the palliative care group (p = 0.002). HADs scores, however, did not show clinically relevant levels of anxiety or depression. At three months, there was no difference between groups in fatigue, anxiety, or overall symptom burden. During hospitalization, caregivers of intervention patients reported less increase in depression (p = 0.03). Caregivers of those in the intervention group reported improvement in coping compared to those in the control group (p = 0.02).

Palliative care during hospitalization for HCT was associated with lower fatigue and symptoms of anxiety and depression.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Unintended interventions or applicable interventions not described that would influence results
• Measurement validity/reliability questionable
• Other limitations/explanation: Interventions for symptom control were not described. Anxiety and depression scores were not at a clinically relevant level for HADS, so it is unclear that differences seen were meaningful.

Palliative care service can be beneficial to patients for management of symptoms during hospitalization for HCT.

To evaluate feasibility and effectiveness of a brief psychosocial intervention delivered by front-line health professionals as part of a planned stepped integrated care model

Clinical sites were randomized to the intervention or control condition. Those randomized to the intervention received a training manual and had a one-day skill development program focusing on supportive-expressive, CNT, and dignity-conserving strategies. At intervention sites, the level of intervention was determined based on distress thermometer (DT) scores and assigned to trained healthcare providers. Patients with HADS scores of 8-21 received the health provider intervention described, and those with HADS scores of 22 or higher were referred for specialist treatment. Patients were contacted and offered up to four individual sessions by telephone or face to face. Weekly supervision was provided by a psychiatrist in a group setting. Patients completed baseline measurements in clinic visits and follow-up measures were provided via reply paid envelope. A phone reminder was done to encourage completion of follow-up measures. Health professionals who delivered the intervention included oncology nurses, physiotherapists, cancer care coordinators, radiation therapists, and an occupational therapist.

• N = 358   
• AGE: Mean = 58.9 years
• MALES: 29.9%  
• FEMALES: 69.1%
• KEY DISEASE CHARACTERISTICS: Varied tumor types–breast and gynecologic were most prevalent. Seventy-six percent had disease progression.  
• OTHER KEY SAMPLE CHARACTERISTICS: Most were married and not working. Formal education level ranged from less than high school to university education. Patients taking antidepressants were excluded.

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: Australia

Cluster, randomized, crossover, multi-site design

• Hospital Anxiety and Depression Scale (HADS)
• FACT-General for quality of life
• EQ 5D-5L
• Demoralization scale
• Unmet needs

There were no significant differences in outcome measures between those patients in the intervention or control conditions. In the intervention condition, 112 were allocated to written resources, 115 to the brief intervention, and 18 were allocated to specialist treatment. There were no differences in outcomes in any of these groups. Providers involved in delivering the intervention reported that it was difficult to provide this along with the other demands in daily practice.

The brief intervention delivered by various front-line healthcare professionals was insufficient to effectively manage depression or anxiety. The amount of skill development provided to the mix of providers involved may have been insufficient.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Key sample group differences that could influence results
• Measurement/methods not well described
• Intervention expensive, impractical, or training needs
• Subject withdrawals ≥ 10%
• Other limitations/explanation: The timing of follow-up measurement is unclear. The differences in effectiveness according to the provider used for the intervention may be a question. Some of these disciplines have no basic education in psychosocial intervention as part of professional education. Significant education and training for skill development and ongoing clinical supervision are required.

This study did not demonstrate effectiveness of this stepped program and brief intervention by varied healthcare professionals. Other research has shown that nurse-delivered programs can be effective. Many other disciplines do not have the depth of initial education in psychosocial care and may require much more education and training to develop sufficient skill to provide an effective intervention for anxiety and depression.

To study the effect of music on anxiety and depression

Patients listened to music for at least 20 minutes daily for three consecutive days. Music was provided through headphones and consisted of light music selected by experts. Study measurements were done daily after the intervention.

• N = 60   
• AGE: Range = 18-65
• MALES: 57.2%  
• FEMALES: 42.8%
• KEY DISEASE CHARACTERISTICS: 54% had soft tissue tumors; others were bone cancer and leukemia. The majority in both groups had stage IV disease.
• OTHER KEY SAMPLE CHARACTERISTICS: 63% had less than high school education. Baseline HADS score was slightly over 14 in both groups.

• SITE: Single site   
• SETTING TYPE: Not specified    
• LOCATION: India

Two-group, non-random, quasi-experimental

Hospital Anxiety and Depression Scale (HADS)

There was no significant change in HADS scores in the control group. HADS scores declined significantly over the three days of the music group (p < 0.001)

Listening to music was associated with short-term reduction in symptoms of anxiety and depression.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (no appropriate attentional control condition)
• Key sample group differences that could influence results

Listening to music is a low-risk intervention that may be of benefit in managing symptoms of anxiety and depression.

To evaluate acceptability and effects of MBSR on perceived stress and anxiety

Women with breast cancer were randomly assigned to MBSR or usual care groups. The usual care group could receive the MBSR intervention after the study was completed. MBSR was provided in two-hour weekly sessions for eight weeks. Study measures were obtained at baseline, after eight weeks, and three months later. The sessions were provided in groups of 4 to 6 patients. The MBSR intervention did not include a retreat.

• N = 58   
• AGE: Mean = 46.1 years (range = 30-62)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All had breast cancer, most were stage II
• OTHER KEY SAMPLE CHARACTERISTICS: Most had high school education and were of middle income range

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

PHASE OF CARE: Transition phase after active treatment

Single blind RCT

• Posttraumatic Growth Inventory
• State-Trait Anxiety Inventory
• Perceived Stress Scale

Those in the MBSR group showed lower perceived stress scores at eight weeks and three months (p = 0.00); scores also declined in everyone over time (p = 0.00). STAI cores declined more in the MBSR group (p = 0.00), with an effect size of 0.21. State anxiety also declined in everyone over time, with an effect size of 0.39 (p = 0.00).

MBSR had a positive effect to reduce anxiety in this study.

• Small sample (< 100)
• Risk of bias (no appropriate attentional control condition)
• Other limitations/explanation: Usual care was not described. No other interventions, such as medications for anxiety were discussed. Adherence to sessions was not reported.

This study showed that a mindfulness-based stress reduction intervention was associated with reducing anxiety levels in women with breast cancer. This is a low-risk intervention that can be helpful for individuals with cancer who have anxiety.

STUDY PURPOSE: Evaluate benefits of MBSR on psychological distress

TYPE OF STUDY: Meta analysis and systematic review

DATABASES USED: PubMed, EMBASE, and Cochrane Central Register from inception to June 2014

INCLUSION CRITERIA: RCT; comparison of MBSR to usual care; breast cancer; measures psychological outcomes such as anxiety, depression, or stress

EXCLUSION CRITERIA: Other types of cancer; did not use MBSR; unpublished

TOTAL REFERENCES RETRIEVED: 323

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Risk of bias assessment according to the Cochrane handbook. Five studies included were not RCTs, despite this as an inclusion criteria. Only one study showed appropriate randomization and was blinded. Non-RCTs were all high risk of bias.

FINAL NUMBER STUDIES INCLUDED: 8

TOTAL PATIENTS INCLUDED IN REVIEW: 964

SAMPLE RANGE ACROSS STUDIES: 13-336

KEY SAMPLE CHARACTERISTICS: All were women with breast cancer

PHASE OF CARE: Not specified or not applicable

Six studies (536 patients) recorded a significant effect on depression (MD = 5.09, p < 0.00001). Four of these studies were pre-/post-test design studies.  Four studies showed a significant effect on anxiety with MBSR (MD 2.79, p < 0.0001). Four studies investigated long-range results from 1 to 24 months. Two showed sustained effects of MBSR at 12 and 24 months.

MBSR is effective for reducing anxiety and depression among women with breast cancer.

• Limited search
• Limited number of studies included
• Mostly low quality/high risk of bias studies
• Low sample sizes
• It is not clear if all studies used traditional MBSR or the more recently seen shortened version of the intervention. Despite an inclusion criteria of RCT, the majority of studies included were not RCTs.

MBSR can be helpful for patients to reduce anxiety and depression. There is some debate about the best form of delivery and full content of MBSR interventions. Additional research is needed to determine if delivery of the intervention for self care via CD or DVD or via Internet applications is effective. Additional research is also needed to determine if shortened interventions that do not include a retreat are as effective, since the time commitment and cost of a retreat may be prohibitive in some cases.

STUDY PURPOSE: To synthesize the evidence regarding immediate and sustained effects of hypnosis on anxiety in patients with cancer

TYPE OF STUDY: Meta analysis and systematic review

DATABASES USED: Scopus, Medline, PsycINFO, Academic Search Premier, CINAHL, and SDOL

INCLUSION CRITERIA: Hypnosis used as intervention, children or adults with cancer, sufficient data for meta analysis, anxiety was an outcome variable

EXCLUSION CRITERIA: Hypnosis combined with another psychological intervention, comparison of different types of hypnosis

TOTAL REFERENCES RETRIEVED: 1,483

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Assessment of quality based on the Cochrane guidelines for RCTs. 13 studies were RCTs and 7 were quasi-experimental design

FINAL NUMBER STUDIES INCLUDED: 20 

TOTAL PATIENTS INCLUDED IN REVIEW: 878

SAMPLE RANGE ACROSS STUDIES: 25-87

KEY SAMPLE CHARACTERISTICS: The majority of studies were in breast cancer survivors; 6 studies were in children

Across all 20 studies, the immediate effect size was significant in favor of hypnosis (Hedges g = 1.05, p < 0.01). There was also significant heterogeneity. The sustained effect size was also significant in favor of hypnosis (Hedges g = 1.69, p < 0.01) across five studies. Heterogeneity for sustained effects was also significant. Hypnosis was more effective when it combined therapist delivery with self-hypnosis than self-hypnosis only. Higher effect sizes were seen in studies of children, with procedure-related anxiety and studies with RCT design. Analysis suggested publication bias, and showed that smaller studies tended to report more positive results. With adjustment for bias, the effect size was reduced from 1.05 to 0.46.

Hypnosis can be beneficial to manage anxiety among patients with cancer. Therapist delivered alone or in combination with self-hypnosis was more effective than self-hypnosis alone.

• Limited number of studies included
• High heterogeneity
• Low sample sizes
• Varied timing, method of delivery and measurement of outcomes. Sample was too small to do relevant subgroup analyses

Hypnosis may be a helpful intervention to manage anxiety in adults and children with cancer for short- and long-term effects. Therapist involvement was more effective than self-hypnosis alone. For patients with significant anxiety, this may be an intervention to be considered.

To compare the effects of self hypnosis, yoga, and cognitive-based therapy (CBT) on psychological and sleep patient outcomes

Women with non-metastatic breast cancer selected whether they wanted to participate in groups receiving CBT, self hypnosis, or yoga interventions. CBT included six weekly 90 minute group sessions led by trained psychologists. The yoga intervention included six weekly 90 minute group sessions of Hatha yoga and a DVD for use in home practice. Self-hypnosis sessions were 2 hours every two weeks for 12 weeks in small groups. The intervention included tasks and discussions inspired by CBT, with a 15 minute hypnosis exercise at the end of the session. They also received a CD with hypnosis exercises and homework assignments between sessions.

• N = 99   
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All had breast cancer, about 33% participated during treatment with chemotherapy
• OTHER KEY SAMPLE CHARACTERISTICS: On average, all had at least a high school education

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

PHASE OF CARE: Multiple phases of care

Prospective, non-random, three-group trial

• Hospital Anxiety and Depression Scale
• EORTC-QLQ-C30
• Mental adjustment to cancer scale
• Insomnia Severity Index
• Self-report of frequency of practice of interventions provided

The majority of patient selected the hypnosis intervention. Anxiety and depression declined significantly in the yoga and hypnosis groups (p < 0.05). Fatigue and insomnia declined in the hypnosis group (p < 0.05). Most attended at least five sessions and practiced at least weekly at home. All three interventions showed medium effect sizes for change in anxiety (Cohen’s d range = 0.57-0.77).

Yoga and self-hypnosis group sessions were associated with decline in anxiety and depression. Self-hypnosis was also associated with improvement in sleep and fatigue scores.

• Small sample (< 100)
• Baseline sample/group differences of import         
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (no appropriate attentional control condition)
• Key sample group differences that could influence results
• Intervention expensive, impractical, or training needs
• Other limitations/explanation:  Only the CBT group did not have any material for home practice.  Sizes of the sample groups were vastly different, with only 10 people in the CBT group.  Though not statistically significant, the effect size for CBT was moderate, suggesting lack of significance was due to the small sample.  There was no differentiation between women currently in treatment and those not in treatment which could influence results -The hypnosis intervention included elements of CBT, so it is difficult to determine to what extent this versus the self hypnosis approach had effectiveness.  Provision of self hypnosis requires availability of appropriately trained providers.

Findings suggest that self hypnosis can be helpful to reduce anxiety, depression and insomnia in women with breast cancer.  If relevant resources are available to clinicians this could be a low risk and beneficial activity for symptom management.

To test the effect of painting art therapy, provided by a dedicated professional artist, on quality of life and anxiety and depression levels in patients receiving chemotherapy

Patients receiving treatment at an outpatient chemotherapy unit were recruited into the study for 12 weeks. Patients were classified by their exposure to the Painting Art Therapy Program (PATP). One group had prior exposure the the second did not. The third group were patients who declined participation and they were considered the control group. The study investigator who is an experienced art therapist conducted the therapy. Patients participated in watercolor painting and a discussion about the symbolic nature of the paintings, feelings, and thoughts. The investigator artist provided introduction to watercolor. During the chemotherapy infusion, the patient made watercolor paintings. After completions of the painting, patients discussed the meaning and subject of their painting. Patients in the intervention group were also given painting materials for home practice.

• N = 97 (65 in the PATP group and 32 in the control group)    
• AGE: Mean = 50.6 years (range = 22-73)
• MALES: 35%  
• FEMALES: 56%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: 54% metastatic cancer
• OTHER KEY SAMPLE CHARACTERISTICS: In the intervention group, 26 had prior exposure to PATP and 22 did not. The authors did not define what "prior expose" included.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Antalya, Turkey

PHASE OF CARE: Active anti-tumor treatment

Comparative prospective study

• EORTC-QLQ-C30 questionnaire
• Anxiety and depression scores (HADS)
• Analysis of variance (ANOVA) with Bonferroni correction
• Number of paintings finished by a patient (proxy motivation indicator)

All patients reported liking the PATP to some extent. Change in global quality of life and depression scores differed significantly among the three groups (F = 7.87, p = 0.001; and F = 7.8, p = 0.001).  Correlates of change in depression were participation in PATP (F = 7.75, p < 0.001) and baseline depression scores (F = 17.71, p < 0.001). Predictors of the magnitude of change and change in depression were participation in PATP. Patients who had poorer well being showed better improvements by participating in PATP.  Previous exposure to PATP appeared to diminish the benefit obtained by PATP.

The authors showed improved quality of life and relief from depression in patients with the utilization of PATP. They authors demonstrated that watercolor can be an important form of art therapy in maintaining quality of life in patients with cancer. The application is feasible in the outpatient clinic. Patients demonstrated benefit of PATP in close relationship with basal global quality of life and depression scores. Because art is subjective, other forms of art therapy may target different patients more specifically.

• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no random assignment)
• Unintended interventions or applicable interventions not described that would influence results

Art therapy can be an important and feasible intervention for patients on active treatment. Participation in art therapy while receiving chemotherapy treatment can improve quality of life and contribute to decreased depression.

To determine the effect of drawing and writing technique on the anxiety level of children treated for cancer during hospitalization.

A five-day therapeutic program to reduce anxiety of children in treatment for cancer was implemented to understand the effect of continuous therapeutic play. Drawing, writing, and mutual storytelling techniques were pre-arranged in the child’s room. Drawing supplies were given to the children. The State Anxiety Inventory was administered on the first day. Drawing was implemented on the first and third days. Children were asked to draw a picture of a child in the hospital and to write a self-created story with a beginning, a middle, and an end about his or her drawing. Mutual storytelling was implemented on the second and fourth days. While listening to the story of the child, the researcher analyzes the themes and psychological meaning for the child. The researcher responds with a story that is similar but has a more positive ending. On the fifth day, the State Anxiety Inventory is administered for the second time.

• N = 30   
• AGE: Mean = 12.56 years (range = 9-16)
• MALES: 7 (23%)  
• FEMALES: 23 (77%)
• CURRENT TREATMENT: Chemotherapy, combination radiation therapy and chemotherapy
• KEY DISEASE CHARACTERISTICS: Leukemia, solid tumor, lymphoma
• OTHER KEY SAMPLE CHARACTERISTICS: Had received two or more courses of chemotherapy; child and parent consent to participation

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Gazi University, Ankara, Turkey

• PHASE OF CARE: Active anti-tumor treatment
• APPLICATIONS: Pediatrics

Quasi-experimental (pre- and postintervention evaluations of a single group)

• Descriptive data collection
• State Anxiety Inventory
• Wilcoxon test

The five-day program was evaluated on the first and fifth day. The State Anxiety Inventory mean score (38.63 [SD = 4.38]) for children after the intervention decreased when compared to the mean beginning score (42.63 [SD = 4.64])  (Z = -4.57, p < 0.05). Only 2 of the 30 children wanted to keep the drawings after the intervention.

Drawing and writing and mutual storytelling techniques can be used to reduce the anxiety levels of children in treatment for cancer. The five-day program time interval and intervention could be implemented in future research.

• Small sample (< 30)
• Risk of bias (no control group)
• Risk of bias (no random assignment)
• Unintended interventions or applicable interventions not described that would influence results
• Other limitations/explanation: No information was provided on who implemented the writing and drawing program, although there is a mention of nursing staff or the "researcher" doing this but it was not made clear who this was and what training he or she had.

Writing and drawing can enable children to express their emotions and fears in an artistic format. Nurses should use these techniques to help uncover the hospitalized child’s anxiety. Training for interpretation and projective techniques in therapeutic communication with children would be helpful in hospital settings.