School of Health Sciences, University of Surrey, Guildford, UK.
Memorial Sloan Kettering Cancer Center, New York, USA.
Cochrane Database Syst Rev. 2020 Jun 2;6(6):CD007568. doi: 10.1002/14651858.CD007568.pub2.
People with cancer experience a variety of symptoms as a result of their disease and the therapies involved in its management. Inadequate symptom management has implications for patient outcomes including functioning, psychological well-being, and quality of life (QoL). Attempts to reduce the incidence and severity of cancer symptoms have involved the development and testing of psycho-educational interventions to enhance patients' symptom self-management. With the trend for care to be provided nearer patients' homes, telephone-delivered psycho-educational interventions have evolved to provide support for the management of a range of cancer symptoms. Early indications suggest that these can reduce symptom severity and distress through enhanced symptom self-management.
To assess the effectiveness of telephone-delivered interventions for reducing symptoms associated with cancer and its treatment. To determine which symptoms are most responsive to telephone interventions. To determine whether certain configurations (e.g. with/without additional support such as face-to-face, printed or electronic resources) and duration/frequency of intervention calls mediate observed cancer symptom outcome effects.
We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 1); MEDLINE via OVID (1946 to January 2019); Embase via OVID (1980 to January 2019); (CINAHL) via Athens (1982 to January 2019); British Nursing Index (1984 to January 2019); and PsycINFO (1989 to January 2019). We searched conference proceedings to identify published abstracts, as well as SIGLE and trial registers for unpublished studies. We searched the reference lists of all included articles for additional relevant studies. Finally, we handsearched the following journals: Cancer, Journal of Clinical Oncology, Psycho-oncology, Cancer Practice, Cancer Nursing, Oncology Nursing Forum, Journal of Pain and Symptom Management, and Palliative Medicine. We restricted our search to publications published in English.
We included randomised controlled trials (RCTs) and quasi-RCTs that compared one or more telephone interventions with one other, or with other types of interventions (e.g. a face-to-face intervention) and/or usual care, with the stated aim of addressing any physical or psychological symptoms of cancer and its treatment, which recruited adults (over 18 years) with a clinical diagnosis of cancer, regardless of tumour type, stage of cancer, type of treatment, and time of recruitment (e.g. before, during, or after treatment).
We used Cochrane methods for trial selection, data extraction and analysis. When possible, anxiety, depressive symptoms, fatigue, emotional distress, pain, uncertainty, sexually-related and lung cancer symptoms as well as secondary outcomes are reported as standardised mean differences (SMDs) with 95% confidence intervals (CIs), and we presented a descriptive synthesis of study findings. We reported on findings according to symptoms addressed and intervention types (e.g. telephone only, telephone combined with other elements). As many studies included small samples, and because baseline scores for study outcomes often varied for intervention and control groups, we used change scores and associated standard deviations. The certainty of the evidence for each outcome was interpreted using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
Thirty-two studies were eligible for inclusion; most had moderate risk of bias,often related to blinding. Collectively, researchers recruited 6250 people and studied interventions in people with a variety of cancer types and across the disease trajectory, although many participants had breast cancer or early-stage cancer and/or were starting treatment. Studies measured symptoms of anxiety, depression, emotional distress, uncertainty, fatigue, and pain, as well as sexually-related symptoms and general symptom intensity and/or distress. Interventions were primarily delivered by nurses (n = 24), most of whom (n = 16) had a background in oncology, research, or psychiatry. Ten interventions were delivered solely by telephone; the rest combined telephone with additional elements (i.e. face-to-face consultations and digital/online/printed resources). The number of calls delivered ranged from 1 to 18; most interventions provided three or four calls. Twenty-one studies provided evidence on effectiveness of telephone-delivered interventions and the majority appeared to reduce symptoms of depression compared to control. Nine studies contributed quantitative change scores (CSs) and associated standard deviation results (or these could be calculated). Likewise, many telephone interventions appeared effective when compared to control in reducing anxiety (16 studies; 5 contributed quantitative CS results); fatigue (9 studies; 6 contributed to quantitative CS results); and emotional distress (7 studies; 5 contributed quantitative CS results). Due to significant clinical heterogeneity with regards to interventions introduced, study participants recruited, and outcomes measured, meta-analysis was not conducted. For other symptoms (uncertainty, pain, sexually-related symptoms, dyspnoea, and general symptom experience), evidence was limited; similarly meta-analysis was not possible, and results from individual studies were largely conflicting, making conclusions about their management through telephone-delivered interventions difficult to draw. Heterogeneity was considerable across all trials for all outcomes. Overall, the certainty of evidence was very low for all outcomes in the review. Outcomes were all downgraded due to concerns about overall risk of bias profiles being frequently unclear, uncertainty in effect estimates and due to some inconsistencies in results and general heterogeneity. Unsubstantiated evidence suggests that telephone interventions in some capacity may have a place in symptom management for adults with cancer. However, in the absence of reliable and homogeneous evidence, caution is needed in interpreting the narrative synthesis. Further, there were no clear patterns across studies regarding which forms of interventions (telephone alone versus augmented with other elements) are most effective. It is impossible to conclude with any certainty which forms of telephone intervention are most effective in managing the range of cancer-related symptoms that people with cancer experience.
AUTHORS' CONCLUSIONS: Telephone interventions provide a convenient way of supporting self-management of cancer-related symptoms for adults with cancer. These interventions are becoming more important with the shift of care closer to patients' homes, the need for resource/cost containment, and the potential for voluntary sector providers to deliver healthcare interventions. Some evidence supports the use of telephone-delivered interventions for symptom management for adults with cancer; most evidence relates to four commonly experienced symptoms - depression, anxiety, emotional distress, and fatigue. Some telephone-delivered interventions were augmented by combining them with face-to-face meetings and provision of printed or digital materials. Review authors were unable to determine whether telephone alone or in combination with other elements provides optimal reduction in symptoms; it appears most likely that this will vary by symptom. It is noteworthy that, despite the potential for telephone interventions to deliver cost savings, none of the studies reviewed included any form of health economic evaluation. Further robust and adequately reported trials are needed across all cancer-related symptoms, as the certainty of evidence generated in studies within this review was very low, and reporting was of variable quality. Researchers must strive to reduce variability between studies in the future. Studies in this review are characterised by clinical and methodological diversity; the level of this diversity hindered comparison across studies. At the very least, efforts should be made to standardise outcome measures. Finally, studies were compromised by inclusion of small samples, inadequate concealment of group allocation, lack of observer blinding, and short length of follow-up. Consequently, conclusions related to symptoms most amenable to management by telephone-delivered interventions are tentative.
癌症患者会因疾病本身及其治疗方法而出现各种症状。症状管理不当会对患者的预后产生影响，包括身体机能、心理健康和生活质量（QoL）。为了降低癌症症状的发生率和严重程度，人们尝试开发和测试心理教育干预措施，以增强患者的症状自我管理能力。随着医疗服务向患者家庭靠近的趋势，通过电话提供的心理教育干预措施不断发展，以支持对一系列癌症症状的管理。早期迹象表明，这些干预措施可以通过增强症状自我管理来减轻症状的严重程度和痛苦。
评估通过电话提供的干预措施对减轻与癌症及其治疗相关症状的有效性。确定哪些症状对电话干预反应最敏感。确定某些配置（例如有无额外支持，如面对面、印刷或电子资源）以及干预电话的时长/频率是否会介导观察到的癌症症状结局效应。
我们检索了以下数据库：Cochrane对照试验中心注册库（CENTRAL；2019年第1期）；通过OVID检索MEDLINE（1946年至2019年1月）；通过OVID检索Embase（1980年至2019年1月）；通过雅典检索护理学与健康领域数据库（CINAHL）（1982年至2019年1月）；英国护理索引（1984年至2019年1月）；以及PsycINFO（1989年至2019年1月）。我们检索了会议论文集以识别已发表的摘要，以及未发表研究的SIGLE和试验注册库。我们检索了所有纳入文章的参考文献列表以获取其他相关研究。最后，我们手工检索了以下期刊：《癌症》《临床肿瘤学杂志》《心理肿瘤学》《癌症实践》《癌症护理》《肿瘤护理论坛》《疼痛与症状管理杂志》和《姑息医学》。我们将检索范围限制为以英文发表的文献。
我们纳入了随机对照试验（RCT）和半随机对照试验，这些试验将一种或多种电话干预措施相互比较，或与其他类型的干预措施（例如面对面干预）和/或常规护理进行比较，其既定目标是解决癌症及其治疗的任何身体或心理症状，招募临床诊断为癌症的成年人（18岁以上），无论肿瘤类型、癌症分期、治疗类型和招募时间（例如治疗前、治疗期间或治疗后）。
我们采用Cochrane方法进行试验选择、数据提取和分析。在可能的情况下，焦虑、抑郁症状、疲劳、情绪困扰、疼痛、不确定性、性相关症状和肺癌症状以及次要结局以标准化均数差值（SMD）和95%置信区间（CI）报告，我们对研究结果进行了描述性综合分析。我们根据所解决的症状和干预类型（例如仅电话干预、电话干预与其他元素结合）报告研究结果。由于许多研究样本量较小，且干预组和对照组的研究结局基线分数往往不同，我们使用了变化分数和相关标准差。使用推荐分级的评估、制定和评价（GRADE）方法解释每个结局的证据确定性。
32项研究符合纳入标准；大多数研究存在中度偏倚风险，通常与盲法有关。总体而言，研究人员招募了6250人，并对患有各种癌症类型且处于疾病不同阶段的患者进行了干预研究，尽管许多参与者患有乳腺癌或早期癌症，和/或正在开始治疗。研究测量了焦虑、抑郁、情绪困扰、不确定性、疲劳和疼痛等症状，以及性相关症状和一般症状强度和/或困扰。干预措施主要由护士提供（n = 24），其中大多数（n = 16）具有肿瘤学、研究或精神病学背景。10项干预措施仅通过电话提供；其余的将电话与其他元素（即面对面咨询和数字/在线/印刷资源）结合使用。提供的电话数量从1次到18次不等；大多数干预措施提供3次或4次电话。21项研究提供了关于电话干预措施有效性的证据，与对照组相比，大多数研究似乎减轻了抑郁症状。9项研究提供了定量变化分数（CS）和相关标准差结果（或者可以计算得出）。同样，与对照组相比，许多电话干预措施在减轻焦虑（16项研究；5项提供了定量CS结果）、疲劳（9项研究；6项提供了定量CS结果）和情绪困扰（7项研究；5项提供了定量CS结果）方面似乎也有效。由于在引入的干预措施、招募的研究参与者和测量的结局方面存在显著的临床异质性，因此未进行荟萃分析。对于其他症状（不确定性、疼痛、性相关症状、呼吸困难和一般症状体验），证据有限；同样无法进行荟萃分析，且个别研究的结果在很大程度上相互矛盾，难以得出通过电话干预措施对其进行管理的结论。所有试验在所有结局方面的异质性都相当大。总体而言，本综述中所有结局的证据确定性都非常低。由于担心总体偏倚风险概况经常不明确、效应估计存在不确定性以及结果存在一些不一致性和总体异质性，所有结局的证据等级都被下调。未经证实的证据表明，电话干预措施在某种程度上可能在癌症成年患者的症状管理中占有一席之地。然而，在缺乏可靠且同质的证据的情况下，在解释叙述性综合分析时需要谨慎。此外，关于哪种干预形式（仅电话干预与其他元素增强相结合）最有效，各项研究之间没有明确的模式。无法确定哪种电话干预形式在管理癌症患者所经历的一系列癌症相关症状方面最有效。
电话干预为癌症成年患者支持癌症相关症状的自我管理提供了一种便捷方式。随着医疗服务向患者家庭靠近的趋势、资源/成本控制的需求以及志愿部门提供者提供医疗保健干预措施的可能性，这些干预措施变得越来越重要。一些证据支持使用电话干预措施来管理癌症成年患者的症状；大多数证据涉及四种常见症状——抑郁、焦虑、情绪困扰和疲劳。一些通过电话提供的干预措施通过与面对面会议相结合并提供印刷或数字材料而得到增强。综述作者无法确定仅电话干预还是与其他元素结合使用能最有效地减轻症状；似乎很可能这会因症状而异。值得注意的是，尽管电话干预措施有可能节省成本，但所审查的研究中没有一项包括任何形式的卫生经济评估。对于所有癌症相关症状，都需要进一步进行有力且报告充分的试验，因为本综述中研究产生的证据确定性非常低，且报告质量参差不齐。研究人员未来必须努力减少研究之间的变异性。本综述中的研究具有临床和方法学多样性的特点；这种多样性水平阻碍了各项研究之间的比较。至少，应该努力使结局测量标准化。最后，研究因纳入小样本、组分配隐藏不足、缺乏观察者盲法以及随访时间短而受到影响。因此，与最适合通过电话干预措施管理的症状相关的结论是初步的。
