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Abstract
Objectives This study aimed to assess the effects of psychosocial interventions in improving health-related quality of life (HRQoL) in adult patients with incurable cancer.
Methods A systematic search was performed in the MEDLINE, PsycINFO, CINAHL, Scopus and Medic databases to identify randomised controlled trials, quasi-experimental studies and cohort studies from 2004 to March 2024 aiming to influence HRQoL or psychosocial well-being.
Results The systematic search yielded 635 articles. After the removal of duplicates, screening of titles and abstracts, assessment of eligibility and screening of the reference list of included studies, 17 studies were included in the review, and a narrative synthesis was conducted. The delivery of psychosocial interventions varied considerably. They were most often structured, individual, performed in person or remotely, and applied multiple combined methods. Professionals delivering the intervention most often had a background in psychology, nursing or social work. The most frequent outcomes were quality of life, depression and anxiety, measured using multiple different tools. Of the studies, 35% reported significant sustainable improvements. The results favoured individual intervention and the multiple-method approach.
Conclusions The interventions presented as psychosocial interventions have their own characteristics and nature, but evidence of their efficacy is limited. There is an apparent need for research and discussion regarding the definitions, differences and relationships between psychosocial, psychological, social and spiritual interventions in cancer care.
- Cancer
- Communication
- Quality of life
- Supportive care
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Psychosocial interventions show great promise in improving the health-related quality of life for adults with incurable cancer; however, the diversity of these interventions and concerns about the robustness of the evidence create challenges in evaluating their effectiveness.
WHAT THIS STUDY ADDS
The efficacy results of the review support the utilisation of an individual, multiple-method approach, as well as highlight the unique characteristics of psychosocial interventions and the challenges in generating reliable evidence for these interventions.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This review indicates that to provide more robust evidence for the effectiveness of psychosocial interventions, both research and interprofessional discussions need to be initiated to define, differentiate and understand the relationship between psychosocial, psychological, social and spiritual interventions in cancer care.
Introduction
Cancer is curable in many cases, but globally, it remains one of the leading causes of death,1 causing nearly 10 million deaths in 2020, with numbers predicted to increase in the coming years.2 In addition to a shortened life expectancy, incurable cancer and its treatments have a wide range of effects on the patient’s health-related quality of life (HRQoL).3–5 For example, progressive incurable cancer results in debilitating symptoms, impaired body function and deterioration of physical and emotional functioning, all of which negatively affect HRQoL.6 7
HRQoL acknowledges the health aspect of quality of life (QoL) in relation to general QoL. HRQoL focuses on individuals’ perceptions of well-being and their ability to function based on their health status or disease experience.8 Both HRQoL and QoL commonly include individuals’ perceptions of their position in life, their abilities and goals, as well as physical, emotional, psychological and social aspects, along with the environment and perceived contentment.9 10 Psychosocial factors are crucial components of HRQoL for cancer patients.11–13 Many patients with incurable cancer experience depression, anxiety14 15 and distress.15 Although existential suffering is less frequently reported in research, it remains a significant aspect of HRQoL, profoundly affecting patients.16–18 Among the QoL domains—physical well-being, social and family well-being, emotional well-being and functional well-being—for patients with incurable cancer, psychosocial factors such as family, emotional well-being and home/housing are considered their most important, alongside physical health.15
Psychosocial support and its dimensions are often difficult to determine precisely due to their complex nature. The concept of psychosocial has been described as the inter-relation between social factors and individual thoughts and behaviours.19 In the cancer literature, the concept of psychosocial primarily connects to psychiatric and psychological symptoms and care,20–25 social and environmental issues26 27 and spiritual issues.28 Furthermore, according to the US National Cancer Institute, psychosocial support aims to meet the mental, emotional, social and spiritual needs of patients and their families, including counselling, education, group support and spiritual support.29 Due to the complexity of the phenomenon and the challenges in defining it, interventions categorised under the umbrella of oncological psychosocial care are numerous and varied, including, for example, information provision, psychoeducation, coping skills training, cognitive and behavioural psychotherapy, social support, relaxation and hypnosis,30–32 to name a few. In health research, a wide range of search terms or search term combinations has been used for psychosocial interventions like ‘meaning centred’, ‘bereavement therapy’, ‘logotherapy’, ‘rehabilitation’, ‘mediation’, ‘emotional support’, ‘health education’, ‘self-help groups’ and many others.33–37 Martikainen et al38 have argued that within health research, the term psychosocial has been used as an umbrella term referring to everything and nothing in particular.
Over the last 12 years, nine systematic reviews have been conducted23 33 39–45 regarding different aspects of psychosocial interventions for patients with incurable cancer. Two of these focused on a specific cancer type,39 41 four on a specific intervention,23 40 43 44 one on a specific symptom45 and one on a physical symptom outcome.42 Teo et al33 conducted a systematic review to summarise the body of research on psychosocial interventions for patients with advanced cancer without restrictions on intervention targets. Only one systematic review on the effects of psychosocial interventions on the QoL of patients with advanced cancer was published two decades ago,46 highlighting the need for further analysis. In determining intervention effectiveness, these reviews have reported concerns regarding the heterogeneity of studies,39–44 46 difficulties in stating the effectiveness of the studies,23 33 39 40 42 44 45 a low number of randomised controlled trials (RCTs)23 39 44 and quality issues.39 40 44 45
This systematic review aims to assess the effect of psychosocial interventions on improving HRQoL in adult patients with incurable cancer. The specific objectives are to describe (1) how psychosocial interventions are conducted, (2) how the effects of psychosocial interventions are assessed and (3) which psychosocial interventions are effective in improving HRQoL or depression, anxiety, distress and existential suffering. To expand and strengthen the evidence in this systematic review, RCTs, cohort studies and quasi-experimental studies with HRQoL outcomes measured with validated instruments are eligible for inclusion.
Method
Study design
A systematic review was conducted following the guidelines of the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis47 and the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 statement.48
Search strategy
The protocol-based search strategy used in the literature search was developed according to the review’s PICO question:49 as a population (P) of patients with incurable cancer, as an intervention (I) psychosocial intervention and as an outcome (O) HRQoL, depression, anxiety, distress and existential suffering. Comparisons (C) were not determined. Information specialists, together with the first author, developed the search strategy and search terms for the different databases. Synonyms used in the search were ‘neoplasms’ for cancer, ‘advanced’, ‘metastatic’, ‘terminal’, ‘palliative’, ‘end of life’ and ‘hospice’ for incurable and ‘HRQoL’, ‘quality of life’ and ‘QoL’ for HRQoL. Otherwise, specific intervention keywords were not included in the search strategy to avoid biased results.
The primary search strategy was developed for Ovid MEDLINE and adapted as needed for other databases. The full detailed search strategy specified by the database is presented in the supplemental material (online supplemental table 1). A systematic search of the literature to identify targeted studies was conducted in March 2024 by the first author in five databases: Ovid MEDLINE, PsycINFO, CINAHL, Scopus and Medic. The obtained results were filtered to include those published in the last two decades (from the year 2004). Additionally, the references of the included articles were manually searched to identify additional studies.
Supplemental material
Eligibility criteria
The eligibility criteria were established prior to the systematic search. The inclusion criteria were as follows: (a) a population of adult patients with incurable cancer, (b) research designs of RCTs, quasi-experimental studies and cohort studies, (c) an intervention aimed at influencing the HRQoL or psychosocial well-being of the patient, (d) the intervention conducted by professionals within the context of the healthcare system (eg, psychoeducation, interventions of psychosocial support, psychotherapy and other therapies and specific interventions), (e) outcomes of HRQoL or QoL measured by a validated instrument (the primary outcome of the review) or depression, anxiety, distress and existential suffering (secondary outcomes of the review) and (f) published as a peer-reviewed original article in the English language. The exclusion criteria were as follows: (a) a population consisting only of family or caregivers, (b) the effect not measured with the target population and (c) features of the intervention not described.
Selection of studies
Two authors with expertise in the subject context and method (HM and MH) independently screened the identified records by title and keywords and assessed eligibility based on the abstracts. Furthermore, the same authors evaluated the final eligibility from the full text. The selection of included studies was discussed until a consensus was reached by HM and MH. The flowchart of study selection is presented in figure 1.
Preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 flow diagram for study selection.
The identification of these studies yielded 635 articles. After excluding the MEDLINE records in CINAHL and Scopus (n=237) and removing duplicates (n=133), 265 titles and abstracts were screened. In total, 227 records were excluded, and 38 full-text articles were retrieved and assessed for eligibility. One of the reports was not retrieved; the article was not published in an attainable journal in English. A total of 21 reports were excluded: seven due to population factors (eg, the population were not patients with incurable cancer or there were additional patient groups), seven due to outcome factors (eg, outcomes were not reported or measured) and seven due to intervention factors (eg, features of the intervention were not reported or the intervention was combined with medication). Additionally, the reference list of the included studies (n=16) was screened and evaluated, yielding one eligible study, which resulted in a total of 17 eligible studies included in the review. The included studies are presented in table 1.
Studies included in systematic review n=17
Data extraction
The data from the included studies were extracted into the data collection Microsoft Excel worksheet developed based on the systematic review’s PICO and inclusion criteria. Data were extracted by two of the authors (HM and MH).
Risk of bias
The risk of bias was assessed using JBI critical appraisal tools.50 Regarding the variation in the review’s study design eligibility, JBI has a wide range of applicable tools for the assessment of the risk of bias.51
Assessment of risk of bias
The risk of bias was assessed independently and discussed by two authors (HM and MH) until an agreement was reached. 11 of the included studies52–62 were assessed using the JBI Checklist for Randomized Controlled Trials (presented in online supplemental table 2), and six63–68 were assessed using the JBI Checklist for Quasi-Experimental Studies (presented in online supplemental table 3). In the JBI checklist, each question can be answered as Yes, No, Unclear or N/A (not applicable).
Synthesis of the bias
In the assessment of RCTs, 90% of the included studies demonstrated a risk of bias (answers 'No' or 'Unclear') regarding the similarity of treatment groups at baseline. Additionally, 73% of the studies indicated a risk of bias concerning the similarity of treatment groups related to interventions other than the one being studied. In 64% of the studies, there was a risk of bias related to the allocation concealment of treatment groups and the blinding of outcome assessors. Furthermore, 55% of the studies showed a risk of bias in the randomisation process.
In the evaluation of quasi-experimental studies, none of them included a control group. Furthermore, all quasi-experimental studies presented a risk of bias in the measurement of outcomes, particularly concerning the frequency of measurements both before and after the intervention (83% of the studies), the reliability of outcome measurements (50%) and unclear reporting on the consistency of outcome measures (50%).
Synthesis
In the synthesis, an examination of the characteristics of psychosocial interventions, comparisons, populations and settings, outcome assessments and the strength of evidence of the included studies was conducted.69 Proceeding to meta-analyses or subgroup meta-analyses was assessed to be at a high risk of bias due to the heterogeneity of study designs, intervention characteristics and comparisons, as well as the diversity of outcomes, measurements and reporting. Therefore, a narrative synthesis of the gathered data was conducted. In narrative synthesis, systematic reviews focusing on a wide range of issues resulting from multiple studies are systematically analysed and synthesised, primarily through verbal descriptions and explanations.70 The synthesis was guided by the review’s research questions.
Results
Description of included studies
Overall, 17 studies were included; of these, 11 were RCTs52–62 and six were quasi-experimental.63–68 None of the included studies were cohort studies. Most studies were conducted in North America (n=13) and within the last 10 years (n=13). The studies involved between 18 and 192 participants (mean 80 participants; SD 51 participants). For the outcomes of interest, depression (n=9), QoL (n=8) and anxiety (n=8) were the most frequently reported. Additionally, six studies measured distress, and two defined HRQoL as an outcome. None of the studies included existential suffering as an outcome. The studies are presented in table 1.
Conduction of the psychosocial interventions
The conduction of psychosocial interventions varied greatly (table 2). As a broad summary, psychosocial interventions aimed at influencing HRQoL or psychosocial well-being in adult patients with incurable cancer were most often structured, individual, delivered in person or remotely, and used multiple combined methods.
Intervention characteristics of the included studies
All the interventions had a certain level of structure. An individual approach was used in 11 of the studies,52 54 56–58 61 63–66 68 a group approach in five of the studies,53 59 60 62 67 and one study combined both individual and group approaches.55 Furthermore, interventions were delivered remotely in seven of the studies,52 53 58–60 62 68 in person in six of the studies54 57 63–65 67 and both in-person and remotely in four of the studies.55 56 61 66 Most of the interventions applied multiple combined methods (n=7). In addition, three studies applied cognitive behavioural stress management,53 59 62 two Dignity therapy,64 65 two hope-focused56 66 and one cognitive-behavioural therapy,54 one narrative57 and one acceptance and commitment therapy-based58 methods.
The duration of the intervention was typically <2 months, with weekly contact. Professionals delivering the intervention varied; most often, they had backgrounds in psychology or psychiatry (n=6), nursing (n=5) or social work (n=4). Some interventions used a multiprofessional approach (n=3). Most of the time (n=10), the intervention was not limited to a specific phase of the disease regarding life expectancy. However, nine of the included studies were conducted with patients undergoing cancer treatment, and five of the studies' inclusion criteria included a life expectancy of over 6 months (table 1).
Assessment of the effects of the psychosocial interventions
The included studies measured HRQoL and QoL using 11 different validated instruments. However, they did not consistently differentiate between HRQoL and QoL concerning the instruments used. The most common instruments were different subscales of the Functional Assessment of Cancer Therapy (FACT): General (FACT–G),55 59 62 Breast (FACT–B),63 Hepatobiliary (FACT–Hep)64 and Lung (FACT–L).64 The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 15 Palliative scores (QLQ-C15-PAL) were used twice,54 65 and the Quality of Life Questionnaire Core 30 (QLQ-C30) was used once.67 Two of the studies used the linear analogue self-assessment (LASA), one study used the single-item LASA,64 and another study used the 12-item LASA.60 Additionally, the Patient Care Monitor 2 (PCM) global QoL subscale,63 McGill Quality Of Life Questionnaire56 and Spitzer QoL Uniscale60 were used. The details are presented in table 3.
Outcome measurement and results of included studies
The measurement of depression was conducted using six different instruments. The most frequently used were the Patient-Reported Outcomes Measurement Information Systems’ (PROMIS), the 6-item short-form depression measure,52 66 the 4-item short-form depression measure58 and the depression item bank computer adaptive test.59 62 Other instruments included the Hospital Anxiety and Depression Scale (HADS),54 65 67 Patient Health Questionnaire-9 (PHQ-9),54 57 Edmonton Symptom Assessment System (ESAS),54 Structured Interview for Symptoms and Concerns65 and a single-item patient-reported outcome measure.57
Anxiety and distress were measured using four different tools: anxiety was assessed with PROMIS, the 6- and 4-item short-form anxiety measure,52 58 66 HADS,54 65 67 the Memorial Anxiety Scale for Prostate Cancer53 59 and ESAS,54 and distress was measured with the Impact of Event Scale—Revised,59 62 HADS,61 68 the PCM distress subscale63 and the Distress Thermometer.64
Effect of psychosocial interventions in improving HRQoL
The detected effect of this systematic review’s target outcomes in the included studies was limited. Two studies found significant and sustainable improvements (p>0.05) for QoL outcomes,55 56 two for QoL and distress,63 64 one for anxiety, depression and QoL67 and one study for depression and anxiety.52 Overall, six of the included studies (35%) reported significant and sustainable improvements within the study follow-up time in QoL, distress, depression or anxiety. Additionally, two of the studies found significant improvements in QoL60 and anxiety53 at the first measurement point, but the improvements were not maintained later. The remaining nine studies (53%) did not find a significant improvement in the target outcomes of this systematic review. The details are presented in table 3.
Studies that yielded significant and sustainable improvements did not have a clear common denominator, such as delivery format (eg, remote or in person) or method (eg, specific therapeutic approach). However, the results favour individual intervention and the multiple-method approach, as both were used in four of the six studies.
Discussion
This systematic review aimed to assess the effect of psychosocial interventions on improving HRQoL in adult patients with incurable cancer. It also aimed to describe how these interventions are conducted, how the effects are assessed and which interventions are effective in improving HRQoL, depression, anxiety, distress and existential suffering. Assessing the effect of psychosocial interventions on HRQoL proved complex due to challenges with the definition of psychosocial interventions, the limited number of studies using validated HRQoL instruments, heterogeneity in study characteristics and the risk of bias in the included studies.
However, this review provided a preliminary understanding of the characteristics of psychosocial interventions aimed at improving the QoL and emotional well-being of people with incurable cancer.
To avoid biased results, specific intervention keywords—such as psychotherapy, cognitive-behavioural therapy, relaxation, or counselling—were not included in the search strategy. This approach allowed the systematic review to reflect the diversity of what is considered psychosocial interventions in the care of patients with incurable cancer. The interventions varied in terms of setting, structuring, method, duration, frequency and the professionals delivering the intervention. This finding aligns with previous systematic reviews on the care of patients with incurable cancers.33 42 45 46 Notably, without the inclusion of specific intervention keywords in the search phrases, standalone psychotherapy was extremely rare,58 contrasting with previous reviews. However, psychological theories and methods were used in the majority of studies.52–54 58 59 61–63 67 68 Similarly, social and spiritual interventions were absent in the results of this review, suggesting that these interventions are not defined as psychosocial interventions by the original researchers.
Issues with definitions and their impact on summarising research findings have also been noted in the psychological context of cancer care. In a metareview regarding psychological intervention, Hodges et al71 proposed that reviews should not broadly group interventions as psychological but should target specific intervention domains. To address evidence synthesis issues with diverse interventions, Teo et al33 grouped psychosocial interventions into six categories: cognitive behavioural therapy-based, meaning enhancing, dignity therapy, life review and narrative, other counselling, education only and music, writing and others. Such grouping could be beneficial in research, as opposed to the broad and more ambiguous label of ‘psychosocial’. Nevertheless, domain or approach categorisation would not resolve all definition issues when the terms psychosocial intervention and psychosocial support are used so widely and interpretively in research, clinical care and service delivery.
Variations in outcome measures were significant, making it difficult to compare the efficacy of interventions. HRQoL and QoL overlapped in the measurement tools used: FACT55 59 62–64 and EORTC54 65 67 were used to measure both HRQoL and QoL. The FACT tool was originally defined to measure QoL72 but is now referenced as an HRQoL tool,73 while EORTC is defined as a QoL questionnaire.74 Nevertheless, both tools are developed for the cancer population,72 74 in a health and disease context. Issues with QoL and HRQoL definition and measurement are apparent; a systematic review of QoL research in medicine and health sciences75 found that only 6% of studies distinguished QoL from HRQoL. The overlap of measurement tools is somewhat understandable, as the concepts of HRQoL and QoL also overlap.76 With various definitions of QoL,75–77 comprehending the phenomenon and measuring the outcomes is challenging. Researchers determine what definition and measurement tool to use, resulting in large variation and difficulties in forming comparable results.
Assessment of intervention effects is essential in research and clinical patient care. The outcome tools used in the included studies to measure depression, anxiety or distress—ESAS, HADS, PHQ and Distress Thermometer—were also presented as clinical tools to screen distress, depression and anxiety in a review by Grassi et al.78 For clinical significance, a meta-analysis of screening and case-finding tools for depression in cancer79 found that two stem questions (inquiry of low mood and loss of interest) had the best evidence for accuracy and acceptability.
Most studies did not demonstrate significant sustainable improvement in HRQoL, QoL, depression, anxiety or distress. Conforming to the same challenge in demonstrating effectiveness, the evidence for psychosocial and psychological interventions in incurable cancer care has been described as compelling,33 limited40 46 and inconsistent.39 Studies demonstrating improvement were diverse but favoured individual intervention and the multiple-method approach.52 55 56 63 64 67 Supporting the multiple-methods approach, the importance of psychological, social and spiritual interventions has been previously recognised in the palliative setting.80 In contrast, Teo et al33 found meaning-centred psychotherapy to be a favourable psychosocial intervention for improving QoL in incurable cancer care, while Uitterhoeve et al46 identified behaviour therapy as favourable. It is worth noting that in Uitterhoeve et al’s review,46 behaviour therapy was used in 12 of the 13 included trials. Therefore, there was no real comparison between different approaches. The difference in conclusions between our review and previous systematic reviews on psychosocial interventions improving QoL in incurable cancer care may be due to differences in the definition of psychosocial interventions in the systematic search. Unlike our review, Teo et al’s33 and Uitterhoeve et al’s46 systematic reviews included various specified intervention keywords in the search.
Limitations
As a limitation, the results are not fully comparable to those of previous systematic reviews due to the decision to limit the search for psychosocial interventions and not to select and include specific intervention keywords. This resulted in fewer psychological, social and spiritual interventions in the search results. The search phrase has been deliberated and reasoned. Due to the lack of a coherent definition of psychosocial intervention in cancer care, there is a risk of subjectivity and bias when conducting systematic reviews. To avoid bias, the determination of psychosocial intervention was left to the researchers of the original studies.
The presented results regarding the efficacy of interventions should be interpreted with caution and regarded as indicative only. A meta-analysis or subgroup meta-analysis was not conducted due to the heterogeneity and diversity of the included studies. In addition, most of the studies were feasibility or pilot studies,52 54 57 58 60–63 66–68 and there were multiple risks of bias with internal validity in most of the included studies (online supplemental table 2 and 3). This limits the robustness of the conclusions that can be drawn from the efficacy results.
Conclusion
Psychosocial support is an established component of care for patients with incurable cancer. However, there is a lack of consensus regarding the definition and elements of psychosocial interventions. The results suggest that the interventions labelled as psychosocial are distinct from purely psychological or social interventions. They possess their own characteristics, including structured formats, the option for in-person or remote delivery, the use of multiple methods, limited duration and variation in the professionals delivering them. Additionally, evidence regarding the efficacy of psychosocial interventions in improving HRQoL in patients with incurable cancer is limited.
Given the varying approaches and understandings of psychosocial support for patients with incurable cancer, interprofessional collaboration regarding roles, distinctions and common ground is essential. Furthermore, there is an evident need for conceptual research and interdisciplinary discussions about the relationships and differences between psychosocial, psychological, social and spiritual interventions in cancer care. The lack of a coherent definition of psychosocial intervention makes it challenging to evaluate efficacy or compare different interventions. Therefore, it is difficult to recommend appropriate care or develop psychosocial support services for patients with incurable cancer in a planned and long-term manner. Concurrently, to achieve clinically meaningful evidence, high-quality, large-sample efficacy studies with a coherent population and coherent methods, outcomes and measures are needed.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
References
Footnotes
Contributors HM contributed to the conceptualisation and design of the review, conducted the literature search, data collection, data analysis and data interpretation together with MH and drafted the manuscript and approved the final manuscript. MH contributed to the conceptualisation and design of the review, conducted the literature search, data collection, data analysis and data interpretation together with HM and provided a critical revision of the manuscript and approved the final manuscript. J-HS and TS contributed to the conceptualisation and design of the review, provided critical revision of the manuscript and approved the final manuscript. KJ supervised the review, contributed to the conceptualisation and design of the review, provided critical revision of the manuscript and approved the final manuscript. HM is guarantor of the review.
Funding The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: The first author was supported by grants from the Nursing Research Center and Comprehensive Cancer Centre, Helsinki University Hospital and the University of Helsinki.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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