Non-pharmacological Interventions to Decrease Anxiety in Advanced Cancer Patients: A Systematic Review D. Zweers RN, MSc; E. de Graaf RN, MSc; Prof. S. Teunissen RN PhD Background Anxiety is a common symptom in palliative care (49-51%) and increases as patients become aware of the ineffectiveness of medical treatments, progression of their illness and their limited life expectancy. Anxiety could affect patients’ decisionmaking and quality of life and requires professional interventions besides support of the self management strategies and patient system. Due to different causes of anxiety and the difficulty to distinguish between psychological and somatic symptoms, the management of anxiety in daily practice is a challenging problem. In this systematic literature review we focus on anxiety ‘as a symptom’ caused by the illness and/or consequences of treatment.
Purpose To provide insight into the effectiveness of nonpharmacological interventions on the management of anxiety in advanced cancer patients. Method: a systematic literature review Pubmed, Embase, Cinahl, PsychINFO and Cochrane were searched. Randomized clinical trials, written in English, evaluated nonpharmacological interventions in advanced cancer patients were included. Data collection and analyses Two authors independently assessed all the retrieved studies. A quality appraisal was conducted using the risk of bias tool (figure 1).
Results Sixteen studies (table 1) were included and categorized into three groups: 1. Telemonitoring interventions and education 2. Psychotherapeutic interventions 3. Complementary care interventions Nine of the 16 interventions were performed by nurses, 5 interventions by psychologists/ therapists and for 2 interventions it was not clear which profession was involved. Only 4 studies in group 1 and 2 showed significant improvement of the experienced anxiety compared with the control group. Commonly success factors in these four effective interventions are shown in figure 2.
Table 1: Overview of included studies First author (year) 1. Breibart (2010) 2. Breibart (2012) 3. Bruera (2008) 4. Chan (2011)
Intervention
Control
N
Outcome
Meaning-centered group psychotherapy Individual Meaning centered psychotherapy Expressive writing
Supportive psychotherapy
-
Psycho educational intervention
Briefing RT procedure+ optional group talk
98 advanced cancer patients 120 advanced cancer patients 24 advanced cancer patients 140 stage 3 or 4 lung cancer patients 174 advanced cancer patients 40 advanced cancer patients
-
108 advanced cancer patients 24 advanced ovarian cancer patients 189 advanced breast colon or prostate cancer
-
207 advanced colorectal cancer patients
-
Medical treatment, adequate symptom management and psychological support Usual care
50 terminally ill cancer patients
+ (p<0,01)
100 advanced cancer patients
-
Equal amount of time with control subjects about general discussions.
56 advanced cancer patients
-
No massage
42 advanced cancer patients 39 advanced cancer patients 87 advanced cancer patients
-
Therapeutic massage Neutral writing group
5. Clayton (2007) 6. Greer (2012)
Question Prompt List
Standard consultation
CBT
Waitlist control group
7. Hans Sang Kim (2013) 8. Henry (2010) 9, Kornblith (2006)
Education + telemonitoring
Education only
Meaning Making Intervention
Usual care
Telephone monitoring + educational materials
Education materials only
10. Leigh (2011)
Decision Aid
Not described
11 Liossi (2001)
Hypnosis, medical treatment, adequate symptom-management and psychological support.
12. LloydWilliams (2012) 13, Sloman (2002)
Focused narrative interview
14, Soden (2004) 15, Toth (2013) 16. Wilkinson ( 1999)
A: Progressive muscle relaxation training B: Guided Imagery training C: A+B A Aromatherapy B: Massage A: Massage therapy B: No-touch intervention Aromatherapy
Usual care Massage
Sampling High Risk
+ (p=0,005)
Other Bias
Unclear Risk
Low Risk
Selective Reporting Incomplete Outcome Blinding of Outcome Blinding of Participants
+ (p=0,05)
Allocation Concealment Random Sequence Generation 0 20 40 60 Figure 1: Methodological quality of included studies
80
100
+ (p<0,0001)
Scheduled monitoring of anxiety
Success Factors Flexibility in order to address individual needs Effective in short time period
-
Opportunity for patient to tell their story
Accessible in an easy way
Integrative treatment focus on multidimensionality of anxiety
Figure 2: Success factors
Conclusion and recommendations Anxious patients are in need for evidence based interventions. Accessibility and effectiveness in a short time period are not only responsible for effectiveness of the intervention but seems also responsible for the feasibility. It is obvious that interventions must fit in the underlying cause of anxiety. However, this systematic review shows a limited set of evidence based interventions to make this fit. The challenge for further development of the interventions as well as the research asks for multidisciplinary collaboration to decide for the best applicable methods to include this vulnerable patient population. The ultimate goal is to develop a stepped care approach which could create a solid foundation for intervention development for patients with high complex profiles.
4th International seminar of the PRC and EAPC RN, Amsterdam
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