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Cognitive behavioral therapy techniques for distress and pain in breast cancer patients: a meta-analysis |
Tatrow K, Montgomery G H |
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CRD summary This poorly reported review assessed the effects of cognitive-behavioural therapy (CBT) on the management of pain and distress experienced by breast cancer patients. The authors concluded that there was evidence to support the use of CBT, but that better quality studies are needed. The review has several methodological weaknesses and the conclusions about effectiveness may not be reliable.
Authors' objectives To assess the effects of cognitive-behavioural therapy (CBT) techniques for distress and pain in breast cancer patients.
Searching PsycINFO, MEDLINE, Cancerlit and CINAHL were searched from 1974 to June 2004; the search terms were reported. Additional studies were identified through searches of literature reviews and meta-analyses on the psychological management of cancer symptoms, as well as from the reference lists associated with these studies. The searches were limited to studies published in the English language.
Study selection Study designs of evaluations included in the reviewRandomised controlled trials (RCTs) were eligible for inclusion if they reported sufficient data to allow the calculation of effect sizes (ESs) (e.g. both means and standard deviations or both P- and n-values given). Trials with stratified random sampling and block randomisation were allowed since these trials had an ES within the range of the overall sample of trials included.
Specific interventions included in the reviewStudies that compared CBT techniques with no treatment or standard care were eligible for inclusion. The review broadly defined CBT as any intervention containing components of either behavioural and/or cognitive techniques: activity pacing, assertiveness or communication training, autogenic training, behavioural activation, biofeedback, cognitive or attentional distraction, cognitive restructuring, contingency management, goal setting, imagery, hypnosis, meditation, modelling, pleasant activity scheduling, problem-solving, relaxation training, role playing, systematic desensitisation or visualisation. The interventions in the individual studies were aimed at individuals or groups of individuals, including couples (details were reported).
Participants included in the reviewStudies of patients with breast cancer were eligible for inclusion. Some of the included studies were in women with early stage breast cancer, some were in women with metastatic cancer, and some were in patients with mixed disease severity.
Outcomes assessed in the reviewThe primary outcomes were measures of pain and distress. Measures that contained questions examining sensory components of pain (e.g. intensity, frequency, duration, or sensation) were included, whereas measures not directly assessing pain (e.g. predicted ability to control pain) were not included. The most common measures of pain employed in the included studies used visual analogue scales. Distress focusing on emotional aspects and studies that utilised measures examining distress, depression, anxiety, stress or mood were included. The most common measure of distress employed in the included studies was the Profile of Mood States.
How were decisions on the relevance of primary studies made?The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.
Assessment of study quality The authors did not state that they assessed validity.
Data extraction The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.
ESs were calculated for pain and distress by taking the difference between the control group mean and the experimental group mean, then dividing by the standard deviation for the control group, according to methods reported by Smith et al. (see Other Publications of Related Interest). Where such data were unavailable, ESs were estimated using and P-values. If a study reported more than one measure of a given outcome (e.g. two measures of distress) or post-intervention time period (e.g. 1 month and 3 months post-intervention), the ESs were calculated as an average of the measures or time periods.
Methods of synthesis How were the studies combined?The pooled mean ES and 95% confidence interval (CI) were calculated using both unadjusted and adjusted methods (by sample size).
How were differences between studies investigated?Differences between the studies were reported in the data tables and text. Subgroup analyses were used to examine the influence of the following factors on unadjusted ES: treatment format (group versus individual therapy); cancer severity (metastases versus no metastases); amount of patient contact; and method of obtaining ES (estimated or calculated). In addition, any possible differences and correlations between ES for pain and distress were investigated. The authors also reported investigating whether the amount of patient contact was correlated with the ES.
Results of the review Twenty studies were included. Thirty ESs (23 for distress and 7 for pain) were calculated from these 20 studies. The total number of participants was 1,649 for distress and 484 for pain. Fifteen studies focused on interventions aimed at individuals, eight focused on groups and one focused on couples.
The overall ES (d) was 0.31 (95% CI: 0.07, 0.55, P<0.05) for distress and 0.49 (95% CI: 0.09, 0.90, P<0.05) for pain, indicating that, overall, breast cancer patients who were administered CBT techniques had significantly less distress and pain compared with those in control group. The results were then adjusted to take variations in sample size into account. The average adjusted ES (D) was 0.13 (95% CI: -0.02, 0.29, P>0.05) for distress and 0.15 (95% CI: -0.13, 0.42, P>0.05) for pain, suggesting that studies with larger sample sizes had smaller effects. Larger studies tended to be those employing group interventions.
Secondary analyses according to treatment format (i.e. individual versus group therapy) showed that the mean distress ES for the individual format was significantly greater than that for the group format (t(21)=2.23; P<0.05). For pain, the mean ES for the individual format was not significantly greater than the group format (P>0.05), but the effect was in the same direction as distress. No significant differences were reported between women with metastases and those without. No significant differences were reported between pain and distress (t(28)=-0.72, P=0.475), and the correlation (r) between distress and pain in the 6 studies that reported both measures was 0.78 (P=0.07). The correlation between the amount of patient contact and ES was not significant (r=0.03, P=0.41).
Authors' conclusions Overall, the results support the use of CBT techniques aimed at individuals to manage distress and pain in breast cancer patients. However, more well-designed studies are needed.
CRD commentary This review was based on clear inclusion criteria, but there are several concerns about the review methodology. The review was only based on data published in English and there appeared to have been little, if any, attempt to locate unpublished data. This suggests that the findings may be affected by publication bias. The authors failed to report how studies were selected for inclusion in the review and how the data were extracted, which may lead to selection bias and inaccuracies in data collection. It also appeared that the validity of the included studies was not assessed, which, given the nature of the studies and the use of subjective outcome measures, was a significant omission.
The studies were pooled using meta-analysis without any assessment of or comment on heterogeneity between the studies, and it was difficult to judge whether pooling was appropriate because no meta-analysis graphs were drawn. It was not clear whether the decision to use unadjusted ES for the main analyses (and subgroup analyses) was taken a priori or post hoc and this may be a source of bias. In addition, ESs were often based on small sample sizes and so need to be interpreted with care. Overall, the authors' conclusions should be treated with caution given the aforementioned concerns about the methodology and data used.
Implications of the review for practice and research Practice: The authors did not state any implications for practice.
Research: The authors stated that additional large-sample studies of individual treatment format (which could be included in future meta-analyses), as well as studies directly comparing individual to group treatment format, are needed.
Funding NCI, grant numbers CA86562, CA87021 and CA88189; ACS, grant number 00-312-01; Department of Defense, grant number DAMD17-99-1-9303.
Bibliographic details Tatrow K, Montgomery G H. Cognitive behavioral therapy techniques for distress and pain in breast cancer patients: a meta-analysis. Journal of Behavioral Medicine 2006; 29(1): 17-27 Other publications of related interest Smith ML, Glass GV, Miller TI. The benefits of psychotherapy, Baltimore: John Hopkins University Press; 1980.
Indexing Status Subject indexing assigned by NLM MeSH Breast Neoplasms /psychology; Cognitive Therapy; Female; Humans; Pain /psychology; Pain Management; Pain Measurement; Psychotherapy, Group; Stress, Psychological /complications /psychology /therapy; Treatment Outcome AccessionNumber 12006001299 Date bibliographic record published 30/11/2006 Date abstract record published 30/11/2006 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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