Effects of Psychoeducational Intervention for Cancer Survivors: A Systematic Review and Meta-Analysis

Jin-Hee Park; Sun Hyoung Bae

doi:10.4040/jkan.2017.47.2.143

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Park and Bae: Effects of Psychoeducational Intervention for Cancer Survivors: A Systematic Review and Meta-Analysis

Review Article

Journal of Korean Academy of Nursing 2017; 47(2): 143-163.

Published online: 28 April 2017

DOI: https://doi.org/10.4040/jkan.2017.47.2.143

Effects of Psychoeducational Intervention for Cancer Survivors: A Systematic Review and Meta-Analysis

Jin-Hee Park, Sun Hyoung Bae

College of Nursing · Nursing Research Institute, Ajou University, Suwon, Korea.

Address reprint requests to: Bae, Sun Hyoung. College of Nursing · Nursing Research Institute, Ajou University, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea. Tel: +82-31-219-7029, Fax: +82-31-219-7020, shyoung@ajou.ac.kr

Received 23 December 2016 Revised 2 March 2017 Accepted 2 March 2017

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution NoDerivs License. (http://creativecommons.org/licenses/by-nd/4.0/) If the original work is properly cited and retained without any modification or reproduction, it can be used and re-distributed in any format and medium.

Abstract

Purpose

This study was a systematic review and meta-analysis designed to investigate effects of psychoeducational intervention for cancer survivors.

Methods

Ten databases were searched. Two reviewers independently performed the selection of the studies, data extraction and assessment. The risk of bias was assessed using Cochrane Collaboration's tool. To estimate the effect size, meta-analysis of the studies was performed using Comprehensive Meta-Analysis and RevMan programs.

Results

Of 18,781 publications identified, 35 met inclusion criteria, and 25 studies were used to estimate effect size of psychoeducational intervention. Effect sizes (standardized mean difference [SMD]) were heterogeneous and random effects models were used in the analyses. Psychoeducational intervention was effective for quality of life (n=2,410, ES=0.23; 95% CI: 0.09~0.37), coping and self-efficacy (n=179, ES=0.68; 95% CI: 0.26~1.11), anxiety (n=1,786, ES=-0.26; 95% CI: -0.37~-0.15), depression (n=1,910, ES=-0.28; 95% CI: -0.37~-0.18), and psychological distress (n=2,242, ES=-0.31; 95% CI: -0.46~-0.17). Subgroup analysis showed that counseling was the most effective intervention for quality of life, and behavioral therapy was an effective intervention for all positive and negative outcomes. Publication bias was not detected except for psychological distress.

Conclusion

Psychoeducational intervention appears to be effective in improving quality of life and coping and self-efficacy, and it is effective in reducing psychological symptoms in cancer survivors. Behavioral therapy, especially, is commonly effective in improving psychosocial outcomes. However, low-quality evidence, variability in the designs of existing studies, and publication bias suggest that additional high-quality trials should be conducted in the future.

Keywords: Neoplasms, Survivors, Education, Behavior therapy, Meta-analysis

Figures and Tables

Figure 1

Flow diagram of study screening.

Figure 2

Forest plots of the effect of psychoeducational intervention.

Figure 3

Effect sizes of psychoeducational intervention by types of intervention.

Figure 4

Funnel plots of standard error by standardized mean difference.

Table 1

Descriptive Summary of Included Studies

No	Author	Country	Participants			Intervention					Comparison	Main outcome measures	Included in meta-analysis
No	Author	Country	Diagnosis & time since diagnosis/treatment	n	Mean age (yr)	Type	Target	Format	Duration (weeks)	Session	Comparison	Main outcome measures	Included in meta-analysis
1	Ashing (2008)	USA	Cervix 3.5 years post diagnosis	Exp: 15 Con: 8	Exp: 49.86 Con: 55.49	Counselling: Problem focused telephone counselling Education: Health information	Individual	Off-line	12	6	Education	QoL	No
2	Ashing & Miller (2016)	USA	Breast 1~6 years post diagnosis	Exp: 20 Con: 19	All: 55.5	Counselling: Problem focused telephone counselling Education: Health information	Individual	Off-line	16	8	Education	QoL	Yes
3	Björneklett et al. (2012)	Sweden	Breast ≥ 1 year post diagnosis	Exp: 191 Con: 191	Exp: 57.5 Con: 58.5	Behavioral therapy: Relaxation training, mental visualization, nonverbal communication, social activities (eg., concert, museum) Education: Health information, coping information	Group	Off-line	Weekly follow-up for 2 months	Unclear	Usual care	QoL^*, others	Yes
4	Bower et al. (2015)	USA	Breast 4.0 years post diagnosis	Exp: 39 Con: 32	Exp: 46.1 Con: 47.7	Behavioral therapy: Mindfulness, relaxation, mind-body connection, practice of meditation, gentle exercise, problem-solving Education: Health education	Group	Off-line	6	6	Waiting list	Depression, psychological distress^*, others	Yes
5	Bränström et al. (2012)	Sweden	Mixed 14.1% were within 1 year, 54.9% were 1~2 years, and 31.0% were >2 years of post diagnosis	Exp: 32 Con: 39	All: 51.8	Behavioral therapy: Mindfulness (including meditation, relaxation, yoga, group discussion)	Group	Off-line	8	8	Waiting list	Coping and self-efficacy, anxiety, depression, psychological distress^*, others	Yes
6	Classen et al. (2008)	USA	Breast 7.2 years post diagnosis	Exp: 177 Con: 175	Exp: 49.7 Con: 49.8	Counselling: Supportive expressive group therapy Education: Educational material	Group	Off-line	12	12	Educational material	Psychological distress	Yes
7	Crane-Okada et al. (2012)	USA	Breast 9.8 years post diagnosis	Exp: 25 Con: 16	Exp: 66.1 Con: 64.8	Behavioral therapy: Mindfulness, dance/movement therapy (including group discussion)	Group	Off-line	12	12	Dance/movement	QoL^, anxiety^, depression, others	No
8	Dolbeault et al. (2009)	France	Breast Within 1 year post treatment	Exp: 102 Con: 101	Exp: 54.5 Con: 51.6	Behavioral therapy: Cognitive-behavioral strategies Education: Medical information Social support: Peer exchange	Group	Off-line	8	8	Waiting list	QoL, coping and self-efficacy, anxiety, depression, psychological distress, others	Yes
9	Germino et al. (2013)	USA	Breast 1~4 years post treatment	Exp: 167 Con: 146	All: 44.0	Behavioral therapy: Cognitive-behavioral strategies Education: Health education	Individual	Off-line	4	4	Telephone training calls	Coping and self-efficacy, psychological distress, others	No
10	Hershman et al. (2013)	USA	Breast >6 weeks post treatment	Exp: 66 Con: 60	Exp: 53.7 Con: 54.9	Education: Health education using NCI publication and personalized education	Individual	Off-line	1	1	Education using NCI publication	QoL, depression, psychological distress, others	Yes
11	Hoffman et al. (2012)	United Kingdom	Breast 0.8 year post treatment	Exp: 103 Con: 111	Exp: 49.0 Con: 50.1	Behavioral therapy: Mindfulness (body scan, yoga-based stretch, meditation, group discussion, didactic teaching, & home practice)	Group	Off-line	8	8	Usual care	QoL^*, anxiety, depression, psychological distress, others	Yes
12	Jang (2013)	Korea	Breast 1.6 years post diagnosis	Exp: 20 Con: 21	Exp: 45.7 Con: 50.3	Behavioral therapy: Stretching, deep breathing & meditation, warm down movement	Group	Off-line	8	8	Waiting list	QoL, coping and self-efficacy, anxiety, depression, others	Yes
13	Lengacher et al. (2014)	USA	Breast 0.4 years post treatment	Exp: 40 Con: 42	All: 57.2	Behavioral therapy: Mindfulness (including education, meditation, group discussion, supportive interaction)	Group	Off-line	6	6	Usual care	QoL, anxiety, depression, psychological distress, others	Yes
14	Lepore & Helgeson (1999)	USA	Prostate Not present; post treatment status	Exp: 12 Con: 12	Not present	Education: Health education Social support: Peer discussion	Group	Off-line	6	6	Waiting list	QoL, coping and self-efficacy, psychological distress^*, others	No
15	Lerman et al. (2012)	USA	Mixed 3.8 years post diagnosis	Exp: 48 Con: 20	Exp: 57.5 Con: 56.4	Behavioral therapy: Mindfulness-based stress reduction (meditation, yoga, mindful communication skills, mindful breast self-examination)	Group	Off-line	8	6	Waiting list	QoL^*, others	No
16	Loprinzi et al. (2011)	USA	Breast 10.0% were 1~3 year, 40% were 3~5 years, and 50.0% were >5 years of post diagnosis	Exp: 12 Con: 8	Median: 61 Range: 46~75	Counselling/Behavioral therapy: Stress management and Resiliency training	Group	Off-line	12	2 smallgroup session, a brief individual session, & 3 follow-up telephone calls	Waiting list	QoL, anxiety, psychological distress, others	Yes
17	Marcus et al. (2010)	USA	Breast Not present; post treatment status	Exp: 152 Con: 152	Not present	Counselling: Structured telephone counseling (uncertainty, physical change, self-change, sexuality, relationship, economic change) Education: Information using booklet	Individual	Telephone	48	16	Information (resource directory)	Depression, psychological distress, others	No
18	May et al. (2009)	Netherlands	Mixed 1.3 years post treatment	Exp: 76 Con: 71	Exp: 47.8 Con: 49.9	Behavioral therapy: Cognitive-behavioral therapy, physical training Education: Health education	Group	Off-line	12	12 for CBT, 6 for PT	Physical training	QoL, others	Yes
19	Meneses et al. (2009)	USA	Breast 1 month~1 year post diagnosis	Exp: 27 Con: 26	All: 53.58	Counselling: Support and education Education: Health education	Individual	Off-line	24	8	Waiting list	QoL	Yes
20	Meneses et al. (2007)	USA	Breast 0.7 years post diagnosis	Exp: 125 Con: 131	All: 54.5	Counselling: Support and education Education: Health education	Individual	Off-line	24	8	Waiting list	QoL	Yes
21	Mishel et al. (2005)	USA	Breast 5~9 years post treatment	Exp: 244 Con: 265	Exp: 64.3 Con: 64.5	Behavioral therapy: Cognitive therapy Education: Health education	Individual	Telephone	4	4	Usual care	Coping and self-efficacy, psychological distress, others	Yes
22	Miyashita (2005)	Japan	Breast 2.0 years post treatment	Exp: 35 Con: 18	Exp: 53.2 Con: 49.5	Education: Health education Social support: Emotional support	Group	Off-line	4	4	Waiting list	QoL, anxiety	Yes
23	Nápoles et al. (2015)	USA	Breast Within 1 year post diagnosis; post treatment status	Exp: 76 Con: 75	Exp: 50.8 Con: 50.2	Behavioral therapy: Cognitive-behavioral stress management skills (including education, supportive interaction)	Group	Off-line	8	8	Usual care	QoL, anxiety, depression, psychological distress*, others	Yes
24	Nelson et al. (2008)	USA	Cervix 1.4 years post diagnosis	Exp: 27 Con: 23	Exp: 49.3 Con: 49.0	Counselling: Individual telephone counselling	Individual	Telephone	9 (including booster at 4 weeks)	5	Usual care	QoL	Yes
25	Osei et al. (2013)	USA	Prostate ≤5 years post diagnosis	Exp: 20 Con: 20	All: 67.2	Education: Health education Social support: Support network	Individual	Off-line	8	Unknown	Information	QoL others	No
26	Park et al. (2012)	Korea	Breast 0.8 year post diagnosis	Exp: 25 Con: 23	Exp: 43.4 Con: 46.8	Counselling: Supportive health-coaching Education: Health education Social support: Small-group meetings	Individual	Off-line	12	6 telephone, 3 small group meetings	Usual care	QoL others	Yes
27	Park et al. (2013)	Korea	Breast 1~5 years post diagnosis	Exp: 15 Con: 5	All: 46.5	Behavioral therapy: Mindfulness-based stress reduction (meditation, body scan, yoga)	Group	Off-line	6	6	Waiting list	QoL, coping and self-efficacy, anxiety, depression, psychological distress, others	Yes
28	Penedo et al. (2004)	USA	Prostate 0.7 year post treatment	Exp: 52 Con: 40	All: 63.1	Behavioral therapy: Cognitive-behavioral stress management skills Education: Information	Group	Off-line	10	10	1 day seminar	QoL, other	Yes
29	Rottmann et al. (2012)	Denmark	Mixed 1.2 years post diagnosis	Exp: 208 Con: 244	Exp: 60 Con: 62	Counselling/social support: Supportive talk with expert, exchange of experiences with peers, informal conversation Behavioral therapy: Physical activity, relaxation, massage, cultural experiences Education: Health education	Group	Off-line	6 days	Unclear	Usual care	QoL, coping and self-efficacy, anxiety, depression, psychological distress	Yes
30	Siddons et al. (2013)	Austrailia	Prostate 1.2 years post treatment	Exp: 34 Con: 26	Exp: 62.85 Con: 63.00	Behavioral therapy: Cognitivebehavioral therapy Education: Health education	Group	Off-line	8	8	Waiting list	QoL, others	No
31	Simpson et al. (2002)	Canada	Breast Not present; post treatment status	Exp: 46 Con: 43	Exp: 50.0 Con: 48.9	Behavioral therapy: Relaxation, stress management techniques, mental imagery, goal setting, planning and achieving change	Group	Off-line	6	6	Education (information package only	Depression, others	No
32	Traeger et al. (2013)	USA	Prostate 0.9 year post treatment	Exp: 148 Con: 109	Exp: 65.9 Con: 64.6	Behavioral therapy: Relaxation, cognitive restructuring, problem-solving, coping skills, interpersonal skills, enhancement of social support network Education: Health education	Group	Off-line	10	10	Half-day seminar	QoL, psychological distress, others	No
33	Willems et al. (2017)	Netherlands	Breast 0.5 year post treatment	Exp: 188 Con: 221	Exp: 56.26 Con: 56.28	Behavioral therapy: Problem-solving and cognitive-behavioral therapy Education: Health education	Individual	On-line	12	8	Waiting list	QoL, anxiety, depression, others	Yes
34	Yun et al. (2013)	Korea	Breast ≤5 years post treatment	Exp: 34 Con: 36	Exp: 56.1 Con: 55.3	Counselling/social support: Discussion for improvement in leadership skills and coaching technique Education: Health education	Group	Off-line	8	Unclear	Waiting list	QoL^*, anxiety, depression, psychological distress, others	Yes
35	Zhang et al. (2016)	China	Mixed 2.0 years post diagnosis	Exp: 24 Con: 23	Exp: 50.9 Con: 51.7	Counselling/social support: Emotional support Behavioral therapy: Progressive muscle relaxation Education: Health education	Group	Off-line	12	Unclear	Usual care	QoL, coping and self-efficacy, psychological distress	Yes

^*Multiple instrument measurement.

CBT=cognitive behavioral therapy; NCI=national cancer institute; PT=physical training; QoL=quality of life.

Notes

This work was funded by the Department of Nursing, Graduate School, Ajou University in Korea.

^{CONFLICTS OF INTEREST} The authors declared no conflict of interest.

Appendix

List of Studies Included in a Systematic Review

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Supplementary Materials

Supplementary 1

Graph for Risk of Bias for Included Studies.

Supplementary 2

Characteristics of Included Studies in a Systematic Review (N=35)

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