The efficacy of interventions to improve psychosocial outcomes following surgical treatment for breast cancer: a systematic review and meta-analysis Hannah Matthews, Professor Elizabeth Grunfeld and Professor Andrew Turner

Breast cancer statistics 1. Breast cancer is the most commonly diagnosed cancer in women across the world. 2. 51, 103 new cases of invasive breast cancer, 2012, UK 3. Almost 8 in 10 women diagnosed with breast cancer in England and Wales survive their disease for ten years or more (2010-11), resulting in a growing cohort of breast cancer survivors. Cancer Research UK

Improved survival rates have placed increased importance on promoting and supporting a high quality of life and optimal psychosocial adjustment, health and wellbeing among breast cancer patients.

Treatments and psychosocial problems The primary treatment for breast cancer is surgical consisting of either a mastectomy or breast conservation surgery (Graham et al., 2014). Approximately one third of women choose to undergo breast reconstruction (Katz et al., 2005). Following breast cancer surgery as many as 30% of women reported experiencing anxiety and depression (Ganz et al., 2002). Body image issues and sexual difficulties are also significantly higher following surgical treatment (Taira et al., 2011).

Study aim… The aim of this meta-analysis was to identify the efficacy of psychosocial interventions for women following breast cancer surgery.

What is a psychosocial intervention? Psychosocial interventions are broadly defined as any supportive interaction involving two or more individuals whose purpose is to promote awareness and education, provide emotional support, encouragement, and assist with problem solving (Sandgren et al., 2000).

Review strategy Search strategy: a keyword search, a subject search, a backward search and a forward search. Databases: PsycINFO, CINAHL, MEDLINE, Academic Search Complete, AMED, Cochrane Library and EMBASE. Inclusion criteria: Included studies employed a quantitative methodology presenting empirical findings focusing on interventions for female breast cancer patients following surgery. A 14 item quality assessment checklist from a standardised quality assessment tool was applied to each study (Kmet, Lee & Cook, 2004). Meta-analysis: hedges g as the effect size statistic.

Search strategy

Review findings Psychosocial interventions: 8 cognitive behavioural therapy interventions 7 psychoeducational interventions Study designs: 22 randomised controlled trials 5 pre and post group evaluations Follow-up periods : 1 to 36 months with between two and six data collection points. Sample sizes : 20 to 442, and the total number of participants across all studies was 4,148. 29 of 32 studies reported significant treatment effects in one or more examined outcomes. 1. The most common psychosocial interventions and study designs were 25 interventions were delivered in person, 6 interventions were delivered via telephone and 1 intervention via videoconferencing.

Meta-analysis results Moderate effect sizes: Anxiety g=0.31 (95% confidence interval of 0.19 to 0.43; p=0.001) Depression g=0.38 (95% confidence interval of 0.24 to 0.52; p=0.001) Quality of life g=0.40 (95% confidence interval of 0.27 to 0.54; p=0.001) Mood disturbance g=0.31(95% confidence interval 0.12 to 0.51; p=0.001) Sleep disturbance g=0.67 (95% confidence interval of 0.29 to 1.05; p=0.001) Body image g=0.40 (95% confidence interval of 0.16 to 0.63; p=0.001) Self-esteem g=0.35 (95% confidence interval of 0.00 to 0.69; p=0.05). Small effect sizes: Sexual functioning g=0.22 (95% confidence interval of -0.07 to 0.50; p=0.14) Distress g=0.27 (95% confidence interval 0.05 to 0.49; p=0.02)

Key findings Anxiety (k=14), depression (k=14) and quality of life (k=13) were the most commonly reported outcomes. Cognitive behavioural therapy was the most common intervention overall and for both anxiety and depression. Clear evidence for the efficacy of cognitive behavioural therapy in improving outcomes in relation to anxiety, depression and quality of life. This is of significant importance given the potential widespread integration of psychosocial interventions in clinical cancer care. This is not surprising given the high incidence of anxiety and depression after surgical treatment for breast cancer, and the widely recognised impact of anxiety and depression on quality of life. However, it is not clear for the other psychosocial outcomes which intervention would be most effective, this should be addressed in future studies. The sample size consists of the number of studies, and is represented by k. T

In summary…. This is the first meta-analysis to demonstrate the efficacy of interventions on a range of psychosocial outcomes following breast cancer surgery. Cognitive behavioural therapy was consistently the most effective psychosocial intervention promoting improvements in anxiety, depression and quality of life. Shortcomings in existing studies: the length of the follow-up period small samples Typically short Limited generalisability of findings was limited Both of which should be addressed in future studies.

References Graham, L.J., Shupe, M.P., & Schneble, E.J. et al. (2014). Current Approaches and Challenges in Monitoring Treatment Responses in Breast Cancer. Journal of Cancer, 5(1),58-68. doi:10.7150/jca.7047. Katz, S.J., Lantz, P.M., & Janz, N.K et al. (2005). Patient Involvement in Surgery Treatment Decisions for Breast Cancer. Journal of Clinical Oncology, 23(24), 5526-5533. Ganz, P.A., Desmond, K.A., & Leedham, B. et al. (2002). Quality of life in long-term, disease-free survivors of breast cancer: a follow-up study. Journal of the National Cancer Institute, (1),39–49. Taira, N., Shimozuma, K., Shiroiwa, T., & Ohsumi, S. et al. (2011). Associations among baseline variables, treatment-related factors and health-related quality of life 2 years after breast cancer surgery. Breast Cancer Research and Treatment, 128(3), 735-47. Sandgren, A., McCaul, K., King, B., O'Donnell, S., & Foreman, G. (2000). Telephone therapy for patients with breast cancer. Oncology Nursing Forum, 27(4), 83-688. Kmet, L.M., Lee, R.C., & Cook, L.S. (2004). Standard quality assessment criertia for evaluating primary research papers from a variety of fields. AHFMR, HTA Initiative, 13,1-21.