Specialist breast care nurses for supportive care of women with breast cancer

Review question

Which interventions carried out by specialist breast care nurses (SBCNs) improve quality of life outcomes for women with a diagnosis of breast cancer?

Why is this question important?

Breast cancer is a complex disease and the most common cancer among women globally. Survival has improved markedly over the last 20 years linked to treatment advances, improved screening and a multi-professional management approach. Breast cancer is not just a physical disease but also impacts on the psychological, emotional and social needs of an individual.

SBCNs are defined as nurses with 'advanced knowledge' who meet women at diagnosis and provide information and emotional support, patient advocacy, and continuity across the care pathway, seeking to address the multifactorial patient's needs. It is important to understand the effectiveness of these interventions which may include using a focussed intervention or the SBCN undertaking new roles within the multidisciplinary team.

How did we identify and evaluate the evidence?

We searched the research literature for randomised controlled trials comparing a SBCN intervention with usual care or other supportive interventions. The primary outcome was quality of life and indicators assessed included general health-related quality of life, cancer-specific quality of life, anxiety and depression, and participant satisfaction. We summarised the evidence from all the studies and considered factors such as how the studies were conducted, and whether the results were consistent.

What did we find?

We found 14 studies with a total of 2905 participants, and four ongoing studies. Thirteen studies involved women with primary disease and one study involved women with advanced disease (sometimes referred to as metastatic or secondary disease). We grouped the studies: psychosocial nursing interventions both in primary disease and in advanced disease and SBCN-led interventions delivering follow-up care.

Psychosocial nursing interventions compared with standard care for women with primary breast cancer

We included nine studies involving 1469 women. The studies tested different types of psychosocial interventions to improve quality of life such as anxiety, depression, distress, emotional and social functioning and physical symptoms; some of these studies measured outcomes up to 18 months using a range of different measurement tools. The evidence suggests that psychosocial interventions carried out by SBCNs for women with a primary diagnosis of breast cancer can improve quality of life and satisfaction with care.

Psychosocial nursing interventions compared with standard care for women with advanced (metastatic) breast cancer

There was only one study which showed that there was no difference in quality of life outcomes at three months following a brief psychosocial nursing intervention compared with standard care for 105 women with newly diagnosed advanced breast cancer.

Specialist breast cancer nurse-led interventions delivering follow-up care for women with primary breast cancer

We included four studies involving 1331 women that reported findings up to five years of follow-up. All four trials showed that SBCN-led follow-up care was equally as effective as standard care for women's quality of life and their satisfaction with care. Overall, the studies captured a specific time point in a person’s care within a role that was multifactorial. No adverse effects or harms were reported. The evidence suggests that, when compared to usual care, SBCN interventions improve health-related quality of life, satisfaction with care, anxiety and depression. SBCN-led follow-up care interventions are equally as effective as usual care for women’s quality of life and satisfaction of care. Overall, the quality of evidence ranged from a very low to moderate levels of certainty and we await the results of ongoing studies to strengthen our confidence in the findings.

There were no SBCN-led follow-up interventions for women with advanced breast cancer.

What does this mean?

The evidence suggests that psychosocial interventions carried out by SBCNs for women with a primary diagnosis of breast cancer, may improve or are at least as effective as standard care for general health-related quality of life, cancer-specific quality of life, anxiety and depression outcomes and satisfaction with care. In future studies, the expertise of the SBCN needs to be better articulated for there to be a meaningful and successful translation to practice, and for SBCNs to have more impact in the area of psychosocial support. Qualification and training of the SBCN needs to be more clearly reported as well as the description of the intervention.

Study funding sources

Two studies did not report on funding, eleven studies reported receiving funding from charities or government institutes, and one study reported that no funding had been received. Two studies reported on the role of the funders.

Search date

11th June 2020.

Authors' conclusions: 

Evidence suggests that psychosocial interventions delivered by SBCNs for women with primary breast cancer may improve or are at least as effective as standard care and other supportive interventions, during diagnosis, treatment and survivorship. SBCN-led telephone follow-up interventions were equally as effective as standard care, for women with primary breast cancer.

Read the full abstract...
Background: 

Interventions by specialist breast cancer nurses (SBCNs) aim to support women and help them cope with the impact of the disease on their quality of life.

Objectives: 

To assess the effects of individual interventions carried out by SBCNs on indicators of quality of life, anxiety, depression, and participant satisfaction.

Search strategy: 

In June 2020, we searched MEDLINE, Embase, CENTRAL (Trials only), Cochrane Breast Cancer Group's Specialist Register (CBCG SR), CINAHL, PsycINFO, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and Clinicaltrials.gov.

Selection criteria: 

We selected randomised controlled trials (RCTs) of interventions carried out by SBCNs for women with breast cancer, which reported indicators of quality of life, anxiety, depression, and participant satisfaction.

Data collection and analysis: 

The certainty of the evidence was evaluated using the GRADE approach. A narrative description of the results including structured tabulation was carried out.

Main results: 

We included 14 RCTs involving 2905 women. With the exception of one study (women with advanced breast cancer), all the women were diagnosed with primary breast cancer. Mean age ranged from 48 to 64 years.

Psychosocial nursing interventions compared with standard care for women with primary breast cancer

Eight studies (1328 women, low-quality evidence) showed small improvements in general health-related quality of life or no difference in effect between nine weeks and 18 months. Six studies (897 women, low-quality evidence) showed small improvements in cancer-specific quality of life or no difference in effect between nine weeks and 18 months. Six studies (951 women, low-quality evidence) showed small improvements in anxiety and depression between nine weeks and 18 months. Two studies (320 women, low-quality evidence) measured satisfaction during survivorship; one study measured satisfaction only in the intervention group and showed high levels of satisfaction with care; the second study showed equal satisfaction with care in both groups at six months.

Psychosocial nursing interventions compared with other supportive care interventions for women with primary breast cancer

Two studies (351 women, very-low quality evidence) measured general health-related quality of life. One study reported that psychological morbidity reduced over the 12-month period; scores were consistently lower in women supported by SBCNs alone compared to support from a voluntary organisation. The other study reported that at six months, women receiving psychosocial support by either SBCNs or psychologists clinically improved from "higher levels of distress" to "lower levels of distress".

One study (179 women, very-low quality evidence) showed no between-group differences on subscales at all time points up to six months measured using cancer-specific quality of life questionnaires. There were significant group-by-time changes in the global quality of life, nausea and vomiting, and systemic therapy side effects subscales, for women receiving psychosocial support by either SBCNs or psychologists at six months. There were improvements in other subscales over time in both groups. Systemic therapy side effects increased significantly in the psychologist group but not in the SBCN group. Sexual functioning decreased in both groups.

Two studies (351 women, very-low quality evidence) measured anxiety and depression. One study reported that anxiety subscale scores and state anxiety scores improved over six months but there was no effect on depression subscale scores in the SBCN group compared to the psychologist group. There was no group-by-time interaction on the anxiety and depression or state anxiety subscales. The other study reported that anxiety and depression scores reduced over the 12-month post-surgery period in the SBCN group; scores were consistently lower in women supported by SBCNs compared to support from a voluntary organisation.

SBCN-led telephone interventions delivering follow-up care compared with usual care for women with primary breast cancer

Three studies (931 women, moderate-quality evidence) reported general health-related quality of life outcomes. Two studies reported no difference in psychological morbidity scores between SBCN-led follow-up care and standard care at 18 to 24 months. One trial reported no change in feelings of control scores between SBCN-led follow-up care and standard care at 12 months.

Two studies (557 women, moderate-quality evidence) reported no between-group difference in cancer-specific quality of life at 18 to 24 months. A SBCN intervention conducted by telephone, as a point-of-need access to specialist care, did not change psychological morbidity compared to routine clinical review at 18 months. Scores for both groups on the breast cancer subscale improved over time, with lower scores at nine and 18 months compared to baseline. The adjusted mean differences between groups at 18 months was 0.7 points in favour of the SBCN intervention (P = 0.058). A second study showed no differences between groups for role and emotional functioning measured using cancer-specific quality of life questionnaires in a SBCN-led telephone intervention compared with standard hospital care, both with and without an educational group programme at 12 months. At 12 months, mean scores were 78.4 (SD = 16.2) and 77.7 (SD = 16.2) respectively for SBCN-led telephone and standard hospital follow-up. The 95% confidence interval difference at 12 months was -1.93 to 4.64.

Three studies (1094 women, moderate-quality evidence) reported no between-group difference in anxiety between 12 and 60 months follow-up. One of these studies also measured depression and reported no difference in depression scores between groups at five years (anxiety: RR 1.8; 95% CI 0.6 to 5.1; depression: RR 1.7 95% CI 0.4 to 7.2).

Four studies (1331 women, moderate-quality evidence) demonstrated high levels of satisfaction with SBCN-led follow-up care by telephone between 12 and 60 months.

Psychosocial nursing interventions compared with usual care for women with advanced breast cancer

One study (105 women, low-quality evidence) showed no difference in cancer-specific quality of life outcomes at 3 months.

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