This review investigated the effectiveness of psychosocial interventions on the quality of life of adult patients with advanced cancer. The authors concluded that cognitive-behavioural techniques are beneficial, especially with regard to emotional functioning. However, the findings of the review may not be reliable due to limitations in both the review methodology and the review data.

To determine the effectiveness of psychosocial interventions on the quality of life (QoL) of adult patients with advanced cancer.

MEDLINE, CINAHL and PsycINFO were searched from 1990 to 2002. The full search strategy with keywords was reported in the review. A published method was used to identify controlled studies. Abstracts of relevant papers mentioned in the bibliographies of identified papers were checked. The Science Citation Index was used to find papers that had cited the identified trials. Subject experts were contacted for information on unpublished trials. The authors did not report whether any language restrictions were applied.

Study designs of evaluations included in the review

Controlled studies were eligible for inclusion in the review. All of the included trials were randomised.

Specific interventions included in the review

Studies that assessed one or more psychosocial interventions were eligible for inclusion. Psychosocial interventions were defined as including one or more of the following: counselling/psychotherapy, behaviour therapy, education and the provision of information or social support. Studies that assessed interventions that were not strictly psychosocial (e.g. complementary therapies) were excluded from the review, as were those that used a comparison group other than usual care or attentional control. All but one of the included studies involved behavioural therapy, with or without group support or counselling; one study assessed counselling alone. The interventions were mainly given in an out-patient or home care setting, and were delivered by either nurses or nurses with psychologists or psychotherapists. The included trials involved both group and individual therapy. Details of the interventions were described in the review.

Participants included in the review

Studies that involved adult patients (aged at least 18 years) with advanced (stage IV) cancer were eligible for inclusion. Studies were excluded if less than 50% of the study population did not have advanced cancer. The included studies involved patients with an average age of 50 to 67 years. Seven trials involved only women with breast cancer; another six involved patients with any cancer. The average proportion of patients with advanced cancer (stage IV) ranged from 63 to 100%. Inclusion and exclusion criteria for individual studies were reported.

Outcomes assessed in the review

Studies that reported one or more measures of QoL were eligible for inclusion. Only measures assessed immediately post-intervention were included. The included studies assessed heterogeneous outcomes, including emotional distress (5 measures), coping (7 measures), physical functioning (6 measures) and a global measure of QoL (4 measures). Details of the individual study outcomes were reported.

How were decisions on the relevance of primary studies made?

Two reviewers independently assessed studies for inclusion. Any disagreements were resolved through discussion or, in the absence of consensus, a third reviewer made a decision.

Two reviewers independently assessed the methodological quality of the included studies. They used a scoring system comprising nine published criteria to assess internal validity. A pre-designed table was used to standardise scoring and any disagreements were resolved by consensus.

Two reviewers independently extracted the data using predefined tables. Any disagreements were resolved through discussion. The magnitudes of effects on each outcome measure were reported as the magnitudes of differences in change scores between groups, relative to the scale used.

How were the studies combined?

Owing to clinical heterogeneity between the studies, trials were grouped according to the type of intervention and the type of outcome measure, and a narrative synthesis undertaken.

How were differences between studies investigated?

Some differences between the studies were evident from the text and tables of the review.

A total of 10 studies were identified. When a study compared more than one intervention arm with the control arm, each intervention arm was labelled as a separate trial; this resulted in the authors stating that 13 trials (870 patients) had been included.

Methodological quality.

All studies used adequate methods of randomisation. Only 5 studies reported using adequate methods of allocation concealment, and only 7 reported adequate details of the numbers and reasons for participant withdrawals.

Emotional functioning - distress (10 trials).

A statistically significant beneficial effect of the intervention was found for anxiety (1 trial of behaviour therapy and social support), patient self-esteem (1 trial of behaviour therapy and social support) and depression (5 trials: one behaviour therapy; three behaviour therapy and social support; one counselling and behaviour therapy). No effect of individual counselling on death anxiety was found.

Emotional functioning - coping (6 trials).

Five trials (one counselling alone; two behaviour therapy alone; one counselling and behaviour therapy; and one behaviour therapy and social support) found a statistically significant beneficial effect of the intervention on the patients' coping abilities. Two trials found that individual behavioural therapy significantly improved a patient's perceived ability to control pain, while another found a significant reduction in patient denial.

Physical functioning (5 trials).

Two trials found that a nursing intervention for breathlessness significantly improved patient's distress relating to breathlessness, activity levels and functional abilities.

Global measures of QoL (5 trials).

Three trials (two behaviour therapy and one behaviour therapy and counselling) found the intervention significantly improved QoL on the Function Living Index (cancer) scale.

Psychosocial interventions using cognitive-behavioural techniques are beneficial for the QoL of patients with advanced cancer, especially in the domain of emotional functioning.

This review answered a clear research question and was supportedby clearly defined inclusion criteria. Details of the search strategy were provided and attempts were made to reduce the risk of publication bias. The authors did not report the use of language restrictions, however, 3 studies were excluded as they could not be translated into English. Some studies may also have been missed by only including studies published from 1990 onwards and through failing to search certain potentially relevant databases (e.g. PsycLIT). Appropriate steps were taken to reduce the risk of error and bias during the study selection, validity assessment and data extraction processes: two reviewers independently assessed studies at each stage. However, details of the validity of the individual studies were not provided and the authors stated that methodological details were often poorly reported. The authors also appear not to have considered individual study quality when synthesising the data. However, given differences between the studies and the study outcome measures, the use of a narrative synthesis would appear reasonable. Data tables reported the statistical significance of outcome differences and not actual effect data. The outcome measures also varied considerably and the authors acknowledged that some studies suffered from methodological problems. Overall, considering these limitations, the authors themselves acknowledge that their conclusions may not be reliable.

Practice: The authors stated that health professionals should consider an intervention involving techniques of behaviour therapy to address emotional distress in patients with advanced cancer.

Research: The authors stated that further research should compare different types of behaviour therapy, as well as consider the spiritual domain of QoL.

ZONMW (the Netherlands Organisation for Health Research and Development).

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.