Bennett Sally, Pigott Amanda, Beller Elaine M, Haines Terry, Meredith Pamela, Delaney Christie
Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia, 4072.
Cochrane Database Syst Rev. 2016 Nov 24;11(11):CD008144. doi: 10.1002/14651858.CD008144.pub2.
BACKGROUND: Cancer-related fatigue is reported as the most common and distressing symptom experienced by patients with cancer. It can exacerbate the experience of other symptoms, negatively affect mood, interfere with the ability to carry out everyday activities, and negatively impact on quality of life. Educational interventions may help people to manage this fatigue or to cope with this symptom, and reduce its overall burden. Despite the importance of education for managing cancer-related fatigue there are currently no systematic reviews examining this approach. OBJECTIVES: To determine the effectiveness of educational interventions for managing cancer-related fatigue in adults. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), and MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, OTseeker and PEDro up to 1st November 2016. We also searched trials registries. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of educational interventions focused on cancer-related fatigue where fatigue was a primary outcome. Studies must have aimed to evaluate the effect of educational interventions designed specifically to manage cancer-related fatigue, or to evaluate educational interventions targeting a constellation of physical symptoms or quality of life where fatigue was the primary focus. The studies could have compared educational interventions with no intervention or wait list controls, usual care or attention controls, or an alternative intervention for cancer-related fatigue in adults with any type of cancer. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies for inclusion and extracted data. We resolved differences in opinion by discussion. Trial authors were contacted for additional information. A third independent person checked the data extraction. The main outcome considered in this review was cancer-related fatigue. We assessed the evidence using GRADE and created a 'Summary of Findings' table. MAIN RESULTS: We included 14 RCTs with 2213 participants across different cancer diagnoses. Four studies used only 'information-giving' educational strategies, whereas the remainder used mainly information-giving strategies coupled with some problem-solving, reinforcement, or support techniques. Interventions differed in delivery including: mode of delivery (face to face, web-based, audiotape, telephone); group or individual interventions; number of sessions provided (ranging from 2 to 12 sessions); and timing of intervention in relation to completion of cancer treatment (during or after completion). Most trials compared educational interventions to usual care and meta-analyses compared educational interventions to usual care or attention controls. Methodological issues that increased the risk of bias were evident including lack of blinding of outcome assessors, unclear allocation concealment in over half of the studies, and generally small sample sizes. Using the GRADE approach, we rated the quality of evidence as very low to moderate, downgraded mainly due to high risk of bias, unexplained heterogeneity, and imprecision.There was moderate quality evidence of a small reduction in fatigue intensity from a meta-analyses of eight studies (1524 participants; standardised mean difference (SMD) -0.28, 95% confidence interval (CI) -0.52 to -0.04) comparing educational interventions with usual care or attention control. We found low quality evidence from twelve studies (1711 participants) that educational interventions had a small effect on general/overall fatigue (SMD -0.27, 95% CI -0.51 to -0.04) compared to usual care or attention control. There was low quality evidence from three studies (622 participants) of a moderate size effect of educational interventions for reducing fatigue distress (SMD -0.57, 95% CI -1.09 to -0.05) compared to usual care, and this could be considered clinically significant. Pooled data from four studies (439 participants) found a small reduction in fatigue interference with daily life (SMD -0.35, 95% CI -0.54 to -0.16; moderate quality evidence). No clear effects on fatigue were found related to type of cancer treatment or timing of intervention in relation to completion of cancer treatment, and there were insufficient data available to determine the effect of educational interventions on fatigue by stage of disease, tumour type or group versus individual intervention.Three studies (571 participants) provided low quality evidence for a reduction in anxiety in favour of the intervention group (mean difference (MD) -1.47, 95% CI -2.76 to -0.18) which, for some, would be considered clinically significant. Two additional studies not included in the meta-analysis also reported statistically significant improvements in anxiety in favour of the educational intervention, whereas a third study did not. Compared with usual care or attention control, educational interventions showed no significant reduction in depressive symptoms (four studies, 881 participants, SMD -0.12, 95% CI -0.47 to 0.23; very low quality evidence). Three additional trials not included in the meta-analysis found no between-group differences in the symptoms of depression. No between-group difference was evident in the capacity for activities of daily living or physical function when comparing educational interventions with usual care (4 studies, 773 participants, SMD 0.33, 95% CI -0.10 to 0.75) and the quality of evidence was low. Pooled evidence of low quality from two of three studies examining the effect of educational interventions compared to usual care found an improvement in global quality of life on a 0-100 scale (MD 11.47, 95% CI 1.29 to 21.65), which would be considered clinically significant for some.No adverse events were reported in any of the studies. AUTHORS' CONCLUSIONS: Educational interventions may have a small effect on reducing fatigue intensity, fatigue's interference with daily life, and general fatigue, and could have a moderate effect on reducing fatigue distress. Educational interventions focused on fatigue may also help reduce anxiety and improve global quality of life, but it is unclear what effect they might have on capacity for activities of daily living or depressive symptoms. Additional studies undertaken in the future are likely to impact on our confidence in the conclusions.The incorporation of education for the management of fatigue as part of routine care appears reasonable. However, given the complex nature of this symptom, educational interventions on their own are unlikely to optimally reduce fatigue or help people manage its impact, and should be considered in conjunction with other interventions. Just how educational interventions are best delivered, and their content and timing to maximise outcomes, are issues that require further research.
背景:癌症相关疲劳被报道为癌症患者最常见且痛苦的症状。它会加剧其他症状,对情绪产生负面影响,干扰日常活动能力,并对生活质量产生负面影响。教育干预可能有助于人们应对这种疲劳或症状,并减轻其总体负担。尽管教育对于管理癌症相关疲劳很重要,但目前尚无系统评价来检验这种方法。 目的:确定教育干预对管理成人癌症相关疲劳的有效性。 检索方法:我们检索了截至2016年11月1日的Cochrane对照试验中心注册库(CENTRAL)、MEDLINE、EMBASE、CINAHL、PsycINFO、ERIC、OTseeker和PEDro。我们还检索了试验注册库。 入选标准:我们纳入了以癌症相关疲劳为主要结局的教育干预随机对照试验(RCT)。研究必须旨在评估专门设计用于管理癌症相关疲劳的教育干预的效果,或评估以疲劳为主要关注点的针对一系列身体症状或生活质量的教育干预的效果。这些研究可以将教育干预与无干预或等待列表对照、常规护理或注意力对照,或针对任何类型癌症的成人癌症相关疲劳的替代干预进行比较。 数据收集与分析:两位综述作者独立筛选研究以纳入并提取数据。我们通过讨论解决意见分歧。与试验作者联系以获取更多信息。第三位独立人员检查数据提取情况。本综述中考虑的主要结局是癌症相关疲劳。我们使用GRADE评估证据并创建了“结果总结”表。 主要结果:我们纳入了14项RCT,涉及2213名不同癌症诊断的参与者。四项研究仅使用了“提供信息”的教育策略,而其余研究主要使用了提供信息的策略并结合了一些解决问题、强化或支持技术。干预措施在实施方式上有所不同,包括:实施方式(面对面、基于网络、录音带、电话);小组或个体干预;提供的课程数量(从2节到12节不等);以及与癌症治疗完成时间相关的干预时间(治疗期间或治疗后)。大多数试验将教育干预与常规护理进行比较,荟萃分析将教育干预与常规护理或注意力对照进行比较。增加偏倚风险的方法学问题很明显,包括结局评估者缺乏盲法、超过一半的研究中分配隐藏不明确,以及样本量普遍较小。使用GRADE方法,我们将证据质量评为极低到中等,主要由于偏倚风险高、无法解释的异质性和不精确性而降级。八项研究(1524名参与者)的荟萃分析有中等质量证据表明,与常规护理或注意力对照相比,教育干预使疲劳强度略有降低(标准化均值差(SMD)-0.28,95%置信区间(CI)-0.52至-0.04)。我们从十二项研究(1711名参与者)中发现低质量证据,表明与常规护理或注意力对照相比,教育干预对一般/总体疲劳有轻微影响(SMD -0.27,95%CI -0.51至-0.04)。三项研究(622名参与者)有低质量证据表明,与常规护理相比,教育干预对减轻疲劳困扰有中等程度的效果(SMD -0.57,95%CI -1.09至-0.05),这在临床上可能具有重要意义。四项研究(439名参与者)的汇总数据发现,疲劳对日常生活的干扰略有降低(SMD -0.35,95%CI -0.54至-0.16;中等质量证据)。未发现与癌症治疗类型或与癌症治疗完成时间相关的干预时间对疲劳有明显影响,并且没有足够的数据来确定教育干预对疾病阶段、肿瘤类型或小组与个体干预的疲劳影响。三项研究(571名参与者)提供了低质量证据,表明干预组的焦虑有所降低(均值差(MD)-1.47,95%CI -2.76至-0.18),对一些人来说,这在临床上可能具有重要意义。另外两项未纳入荟萃分析的研究也报告了教育干预组焦虑有统计学意义的改善,而第三项研究则没有。与常规护理或注意力对照相比,教育干预在抑郁症状方面没有显著降低(四项研究,881名参与者,SMD -0.12,95%CI -0.47至0.23;极低质量证据)。另外三项未纳入荟萃分析的试验发现,组间在抑郁症状方面没有差异。将教育干预与常规护理进行比较时,在日常生活活动能力或身体功能方面没有明显的组间差异(四项研究,773名参与者,SMD 0.33,95%CI -0.10至0.75),证据质量较低。三项研究中有两项比较教育干预与常规护理效果的汇总证据质量较低,发现0-100量表上的总体生活质量有所改善(MD 11.47,95%CI 1.29至21.65),对一些人来说,这在临床上可能具有重要意义。所有研究均未报告不良事件。 作者结论:教育干预可能对减轻疲劳强度、疲劳对日常生活的干扰和一般疲劳有轻微效果,对减轻疲劳困扰可能有中等效果。专注于疲劳的教育干预也可能有助于减轻焦虑并改善总体生活质量,但尚不清楚它们对日常生活活动能力或抑郁症状可能有何影响。未来进行的其他研究可能会影响我们对这些结论的信心。将疲劳管理教育纳入常规护理似乎是合理的。然而,鉴于这种症状的复杂性,仅靠教育干预不太可能最佳地减轻疲劳或帮助人们应对其影响,应与其他干预措施结合考虑。教育干预的最佳实施方式、其内容和时间安排以最大化效果,是需要进一步研究的问题。
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