Systematic reviews of pain and online interventions for cancer patients show evidence of mixed efficacy and highlight need for more rigorously designed research

Abstract

Two systematic reviews are highlighted in this month's PEC, one exploring educational interventions to reduce cancer-related pain, the other focusing on online interventions for cancer patients. Pain is a common and feared experience of patients living with cancer, particularly at the end of life, and can have a major impact on quality of life, limiting the activities in which people can participate and causing suffering and distress. It has long been reported that cancer-related pain is inadequately treated in routine clinical practice, and there is little evidence of improvement over time [1]. The literature suggests that both patient and health professional barriers contribute to these poor outcomes, with education of both groups recommended to overcome these barriers. Thus the current systematic review of reviews of educational interventions to improve cancer pain outcomes by Adam, Bond, and Murchie [2] is both timely and important.Adam, Bond, and Murchie [2] identified eight systematic reviews summarizing the results of 34 randomised controlled trials, of which two were pilot studies. Thus there is a considerable body of research in this area. Most studies targeted patient and caregiver education, and those that did target health professional education rarely measured patient outcomes. Thus the evidence for impact on patient outcomes of health professional interventions is still very preliminary, and this was identified by the review authors as a major methodological problem that should be addressed in future studies.This review-of-reviews concluded that there is evidence of a small, statistically significant impact of patient/caregiver education intervention on pain intensity, in the order of 1 point on a 10 point scale. The authors rightly question the clinical significance of such a small improvement. Where measured, quality of life and functional outcomes were not impacted by the interventions. As other outcomes that might reflect real benefit, such as reduced emergency visits, were measured in none of the cited studies, it is not clear whether these were impacted. Thus the review highlights the need for our community to pause and reflect on why interventions are not having greater impact, and which factors may be contributing to successful and less successful outcomes [2].Unfortunately the studies included in this review-of-reviews did not provide any answers to these questions. No factors were consistently identified as leading to better outcomes, although some reviews did conclude that factors such as high dose and intensity of intervention [3], and patient characteristics such as having a better prognosis, being an inpatient and having higher baseline pain [4], may increase chances of intervention benefit. A similar summary of eight systematic reviews,

Online psychological interventions to reduce symptoms of depression, anxiety, and general distress in those with chronic health conditions: a systematic review and meta-analysis of randomized controlled trials

“…Studies are needed to identify the effective components of complex interventions such as psychological therapy (Butow & Smith, 2015). As many interventions in this review used multiple intervention components (e.g.…”

Web-based mindfulness and skills-based distress reduction for patients with cancer: study protocol of the multicentre, randomised, controlled confirmatory intervention trial Reduct

“…Treatment guidelines for psycho-oncology emphasise the importance of targeting and reducing distress in patients with cancer 39. The initial results of e-mental health interventions have been promising for patients with cancer 10 11 56. Accordingly, RCTs are needed to evaluate e-mental health interventions in psycho-oncological care—especially self-guided interventions, with low cost-intensity and with outreach to outlying regions with limited psycho-oncological offers 11 56–58.…”

“…The initial results of e-mental health interventions have been promising for patients with cancer 10 11 56. Accordingly, RCTs are needed to evaluate e-mental health interventions in psycho-oncological care—especially self-guided interventions, with low cost-intensity and with outreach to outlying regions with limited psycho-oncological offers 11 56–58. Given the increasing impact of digital technologies in daily life, the web-based Make It Training has the potential to reach high numbers of patients and to overcome barriers that patients face in analogue face-to-face care (eg, physical and psychological constraints due to cancer symptoms or treatments, limited psycho-oncological resources) 59.…”

E-Mental-Health in der Psychoonkologie: ein multizentrisches Projekt

“…Insbesondere haben sie das Potenzial, Distress 6 , 7 Angst und Depression zu verringern 6 , 8 . Außerdem können sie die allgemeine Lebensqualität von krebserkrankten Patienten verbessern und Nebenwirkungen wie Müdigkeit und Schmerzen verringern 6 , 7 , 9 , 10 .…”