Psychological therapies to reduce tiredness in patients with incurable cancer

Background

Patients with incurable cancer often experience tiredness (fatigue) during cancer treatment. Psychological therapies may help to reduce this symptom. Tiredness in cancer patients receiving cancer treatment may be treated with psychological therapies aimed at influencing or changing thoughts, emotions, behaviours, social interactions, or a combination of these (e.g. cognitive-behavioural therapies, supportive-expressive group therapies). This review looked at how effective psychological therapies are in reducing tiredness in patients with incurable cancer receiving cancer treatment.

Study characteristics

In November 2016, we searched for clinical trials looking at psychological therapies in patients with incurable cancer receiving cancer treatment. We found 14 small studies of very low quality reporting data on tiredness outcomes, 12 of which provided data for analyses. A limited number (three studies) reported results about side effects; these studies investigated a psychological therapy combined with medication.

Key findings

Review authors found no support for the effectiveness of psychological therapies in reducing tiredness when assessed directly following the intervention. Very low-quality evidence suggests that psychological therapies may improve physical functioning directly after the intervention and may improve tiredness at first follow-up. Evidence shows no support for the effectiveness of psychosocial therapies in improving other domains of functioning. Limited evaluation of potential harm suggests no differences in side effects between patients receiving psychological therapy and those given usual care. Limited good quality evidence allows no conclusions on the use of psychological therapies in people with incurable cancer. Larger, high-quality trials are needed to find out whether psychological therapies help reduce tiredness for people with incurable cancer during cancer treatment.

Quality of the evidence

We rated the quality of study evidence using four levels: very low, low, moderate, and high. Very low-quality evidence means that we are very uncertain about the results. High-quality evidence means that we are very confident in the results. Included studies had design problems and included a very small number of participants. Therefore, the quality of the evidence in this review is very low, and results of this review should be interpreted with caution.

Authors' conclusions: 

We found little evidence around the benefits of psychosocial interventions provided to reduce fatigue in adult patients with incurable cancer receiving cancer treatment with palliative intent. Additional studies with larger samples are required to assess whether psychosocial interventions are beneficial for addressing fatigue in patients with incurable cancer.

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Background: 

Fatigue is a prevalent and burdensome symptom for patients with incurable cancer receiving cancer treatment with palliative intent and is associated with reduced quality of life. Psychosocial interventions seem promising for management of fatigue among cancer patients.

Objectives: 

To assess the effects of psychosocial interventions for fatigue in adult patients with incurable cancer receiving cancer treatment with palliative intent.

Search strategy: 

We searched the following databases: CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, and seven clinical trial registries; we also searched the reference lists of articles. The date of our most recent search was 29 November 2016.

Selection criteria: 

We included randomised controlled trials that compared psychosocial interventions in adults aged 18 years or over undergoing cancer treatment with palliative intent for incurable cancer versus usual care or other controls. Psychosocial interventions were defined as various kinds of interventions provided to influence or change cognitions, emotions, behaviours, social interactions, or a combination of these. Psychosocial interventions of interest to this review had to involve at least two interactions between the patient and the care provider in which the care provider gave the patient personal feedback concerning changes sought by these interventions. We included trials that reported fatigue as an outcome of interest.

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane. Two review authors independently considered trials for inclusion in the review, assessed risk of bias, and extracted data, including information on adverse events. We assessed the quality of evidence using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) and created a 'Summary of findings’ table.

Main results: 

We identified 14 studies (16 reports) that met inclusion criteria for this review and involved 3077 randomised participants in total. Most of these studies included a mixed sample of participants; we obtained data for the subset of interest for this review (diagnosis of incurable cancer and receiving cancer treatment) from the study investigators of 12 studies, for which we included 535 participants in the subset meta-analysis for fatigue post intervention. Researchers investigated a broad range of psychosocial interventions with different intervention aims and durations. We identified sources of potential bias, including lack of description of methods of blinding and allocation concealment and inclusion of small study populations.

Findings from our meta-analysis do not support the effectiveness of psychosocial interventions for reducing fatigue post intervention (standardised mean difference (SMD) -0.25, 95% confidence interval (CI) -0.50 to 0.00; not significant; 535 participants, 12 studies; very low-quality evidence). First follow-up findings on fatigue suggested benefit for participants assigned to the psychosocial intervention compared with control (SMD -0.66, 95% CI -1.00 to -0.32; 147 participants, four studies; very low-quality evidence), which was not sustained at second follow-up (SMD -0.41, 95% CI -1.12 to 0.30; not significant; very low-quality evidence).

Results for our secondary outcomes revealed very low-quality evidence for the efficacy of psychosocial interventions in improving physical functioning post intervention (SMD 0.32, 95% CI 0.01 to 0.63; 307 participants, seven studies). These findings were not sustained at first follow-up (SMD 0.37, 95% CI -0.20 to 0.94; not significant; 122 participants, two studies; very low-quality evidence). Findings do not support the effectiveness of psychosocial interventions for improving social functioning (mean difference (MD) 4.16, 95% CI -11.20 to 19.53; not significant; 141 participants, four studies), role functioning (MD 3.49, 95% CI -12.78 to 19.76; not significant; 143 participants, four studies), emotional functioning (SMD -0.11, 95% CI -0.56 to 0.35; not significant; 115 participants, three studies), or cognitive functioning (MD -2.23, 95% CI -12.52 to 8.06; not significant; 86 participants, two studies) post intervention. Only three studies evaluated adverse events. These studies found no difference between the number of adverse events among participants in the intervention versus control group.

Using GRADE, we considered the overall quality of evidence for our primary and secondary outcomes to be very low. Therefore, we have very little confidence in the effect estimate, and the true effect is likely to be substantially different from the estimate of effect. Limitations in study quality and imprecision due to sparse data resulted in downgrading of the quality of data. Additionally, most studies were at high risk of bias owing to their small sample size for the subset of patients with incurable cancer (fewer than 50 participants per arm), leading to uncertainty about effect estimates.

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