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Clinical guidance for responding to suffering in adults with cancer

Appendix 2 - Interventions

Psycho-educational interventions

A psycho-educational intervention can be defined as a behavioural intervention focusing on the improvement of quality of life, including psychological, physical, social and spiritual wellbeing, which incorporates skilful information giving, discussion of concerns, problem solving, coping skills training, expression of emotion, and social support.181, 182Examples include health education programs, telephone counselling and patient empowerment programs. Some interventions target both patients and partners or carers, while others focus only on the individual with the cancer diagnosis.

The nine studies included in the review had different aims and used different tools to assess the outcomes. Seven were randomised controlled trials, one a pseudo-randomised controlled trial, and one a non-randomised experimental trial. The results are inconsistent, particularly regarding spiritual wellbeing, and therefore overall interpretation is difficult. Only five studies assessed spiritual wellbeing specifically, with two finding a positive impact21, 22 and the other three resulting in non-significant changes.182-184 In one study23 a significant change in the intervention group was reported for hopelessness, at least initially. In another study185there was a non-significant change in hopelessness in the intervention group.

However, there were no significant outcomes reported for other measures across all studies. It appears, therefore, that spiritual wellbeing and hopelessness may be positively impacted by certain psycho-educational interventions in some circumstances, but findings are inconsistent and further research is recommended.

The studies listed in Table 1 below include those demonstrating significant changes in the intervention group of at least one of the measured outcomes of suffering.

See the systematic review for full details of assessed studies.2

Table 1: Summary of psycho-educational intervention studies reporting significant findings in the intervention group measuring outcomes of suffering

Study Intervention and control Outcome

Badger (2011)21
USA

Study type
RCT

Level of evidence
Level II

Quality
Strong

Measures
Quality of Life – Breast Cancer (QOL-BC) spiritual wellbeing scale

Two telephone-delivered interventions compared with each other to assess effectiveness of maintaining and improving quality of life for prostate cancer survivors and carers:

A) Interpersonal counselling and cancer education, addressing mood and emotional expression, and facilitating ability to process and adapt to stressful situations (n=36).

B) Health education providing written material about prostate cancer and other cancer topics, but no counselling provided (n=35).

Both interventions delivered over two months; weekly for survivors; fortnightly for carers.

Significant improvement over time in spiritual wellbeing for health education group for both survivors and carers. Improvements also in depression, negative affect, stress and fatigue.

No significant changes over time for the interpersonal counselling group, but survivors did have high QOL at baseline which did not deteriorate over time, and also showed improvements in depression.

Ferguson (2012)22
USA

Study type
RCT

Level of evidence
Level II

Quality
Strong

Measures

Quality of Life – Cancer Survivors (QOL-CS), Multiple Ability Self-Report Questionnaire (MASQ), Centre for Epidemiological Study – Depression (CES-D), Spielberger State-Trait Anxiety Inventory (STAI), Treatment Satisfaction scale.

Breast cancer survivors > 18 months (n=19) post-chemotherapy offered brief cognitive behaviour therapy in the form of Memory and Attention Adaptation Training (MAAT) for management of cognitive dysfunction following chemotherapy. Aim is to give participants compensatory strategies to address chronic memory dysfunction.

Four fortnightly visits with phone contact between visits.

Control: Waitlist (n=21)

Significant improvement in intervention group on spiritual wellbeing subscale of QOL-CS and high participant satisfaction of intervention.

Northouse (2005)23
USA

Study type
RCT

Level of Evidence
Level II

Quality

Strong

Measures

Appraisal of Illness Scale or Appraisal of Caregiving Scale, Mishel Uncertainty in Illness Scale, Beck Hopelessness Scale, the Brief COPE, the FACT scale version three and the SF-36 Health Survey.

Patients with advanced breast cancer and their families (n=94 dyads) completed the FOCUS program to improve family communication, optimistic thinking and coping skills; identify family strengths; and increase knowledge of disease, symptoms and self-care.

Delivered by three monthly nurse visits and two follow-up phone calls.

Control: Usual care (n=88 dyads)

Significantly less patient hopelessness and less negative appraisal of illness than the control group at three months follow-up, but not sustained at six months follow-up.

No difference in quality of life between intervention and control groups.

Delbar (2001)24

Israel

Study type
RCT

Level of Evidence
Level III

Quality
Strong

Measures

Sense of Coherence scale, Multidimensional Health Locus of Control scale, and Symptom Control Assessment, all provided at baseline and six months later after intervention.

Nurses visited patients with early- stage cancer (n=48) to address patient complaints and symptoms. Aim is to increase patients’ internal resources to improve self-care and coping through providing information and emotional support.

Fortnightly visits for three months.

Control:  Usual care (n=46), with patients filling out SOC, MHLC and SCA measures at baseline and six months later.

Decreased intensity of all symptoms, and increased independence, familial help, and knowledge among intervention group, in contrast to either stability or deterioration in control group.

Improvements over time in Sense of Coherence measure in intervention group, but a decrease in SOC over time for control group.

However, intervention and control groups not directly compared, and baseline scores differed significantly.

Intervention worthy of further investigation.

Koinberg (2006)25
Sweden

Study type
Non-randomised experimental trial

Level of evidence
Level III-2

Quality
Good

Measures
Sense of Coherence (SOC), Functional Assessment of Cancer Therapy General Scale (FACT-G), Self-Care Aspects questionnaire (SCA)

Early breast cancer patients (n=50) completed a multidisciplinary education program that included four weekly lectures about different breast-cancer related issues.

Control:  Usual care (n=47), traditional follow-up to a physician twice yearly).

No significant differences between intervention and control regarding Sense of Coherence at baseline or at one-year follow-up.

Although there was no significant change in the intervention group, there was a statistically significant worsening of SOC in control group.

 

Meaning-centred interventions

The aim of meaning-centred interventions is to build and sustain meaning and spirituality into end–of- life care for patients with advanced cancer.17 Interventions studied ranged from therapist-guided life review (e.g. life review and dignity therapy), individual psychotherapy focusing on meaning, and meaning-centred group psychotherapy.

In the five studies included in the review a range of different tools and measures were implemented to assess suffering outcomes.

Overall, four of the five Level II studies15-18 provided evidence suggesting that meaning-centred interventions can significantly and positively impact on meaning in advanced cancer patients. However meaning-centred interventions did not impact on patients’ hopelessness, desire for death or will to live.

In Table 2, meaning-centred intervention studies with statistically significant changes to at least one of the measured suffering outcomes in the intervention group compared with the control group are described.

See the systematic review for full details of assessed studies.2

Table 2: Summary of meaning-centred intervention studies reporting significant findings in the intervention group measuring outcomes of suffering

Study Intervention and control Outcome

Ando (2010)15
Japan

Study type
RCT

 

Level of Evidence
Level II

Quality
Strong

Measures
Functional Assessment of Chronic Illness Therapy-Spiritual (FACIT-Sp) scale, the Hospital Anxiety and Depression Scale (HADS) and items from the Good Death Inventory (Hope, Burden, Life Completion, and Preparation).

Terminally ill cancer patients received a one week Short-Term Life Review (n=38) for the enhancement of spiritual wellbeing, to assess the effect of the therapy on anxiety, depression, suffering, and elements of a good death.

Control: General support in the first and second sessions (n=39).

Intervention group showed significantly greater improvement compared with the control group in The FACIT-Sp, Hope, Life Completion, and Preparation scores.

HADS, Burden, and

Suffering scores in the intervention group also had suggested greater alleviation of suffering compared with the control group.

Breitbart (2010)17
USA

Study type
RCT

 

Level of Evidence
Level II

Quality
Strong

Measures
Beck Hopelessness Scale (BHS), FACIT-Sp, Schedule of Attitudes toward Hastened Death (SAHD), The Life Orientation Test (LOT) and the HADS.

Patients with advanced (stage III or IV) solid tumour cancers completed an 8-week Meaning Centred

Group Psychotherapy (MCGP)(n=49) aimed to enhance a sense of meaning, peace and purpose in patients’ lives at end of life.

Patients were screened for spiritual wellbeing, meaning, hopelessness, desire for death, optimism/pessimism, anxiety, depression and QOL, and were assessed before and after the intervention, and 2 months later by a psychiatrist or clinical psychologist.

Control: Supportive group psychotherapy (SGP) (n=41) consisting of discussion of issues/themes that emerge for patients coping with cancer.

Patients in the MCGP experienced significantly greater improvements in their spiritual wellbeing and a sense of meaning.

Treatment gains were even more substantial (based on effect size estimates) at the second two month follow-up assessment.

Improvements in anxiety and desire for death were also significant at the two month follow- up (and increased over time). There was no significant improvement on any of these variables for patients participating in SGP.

Breitbart (2012)16
USA

Study type
RCT

 

Level of Evidence
Level II

Quality
Strong

Measures
Primary outcome measures assessed

FACIT, Spiritual Wellbeing Scale (SWB) and the McGill Quality of Life Questionnaire (MQOL).

Secondary measures included the HADS, the BHS, the Memorial Symptom Assessment Scale (MSAS), and a clinical status assessment (e.g. cancer diagnosis, treatment history).

Patients with stage III or IV cancer received seven sessions of Individual Meaning-Centred Psychotherapy (IMCP) (n=64).

Patients were assessed before and after the intervention and 2 months post-intervention.

Control: Therapeutic massage (TM)(n=56).

At post-treatment, IMCP participants had significantly greater improvement than the control condition for primary outcomes of spiritual wellbeing (meaning, faith and quality of life measures).

Significantly greater improvements for IMCP patients were also observed for the secondary outcomes of symptom burden and symptom-related distress however not for anxiety, depression, or hopelessness.


However at the 2-month follow-up assessment, the improvements observed for the IMCP group were no longer significantly greater than those observed for the TM group.

 

Henry (2010)18
Canada

Study type
RCT

 

Level of Evidence
Level II

Quality
Strong

Measures
The primary outcome of existential distress was measured by the FACIT-Sp-12 Meaning subscale and the MQOL Existential subscale.

The HADS and the

General Self-Efficacy Scale (GSES) were used to measure anxiety, depression and self-efficacy.

Newly diagnosed patients with Stage III or IV ovarian cancer completed The Meaning-Making intervention (n=12). The Meaning-Making intervention (MMI) is a brief, individualised and manualised therapeutic approach designed to facilitate the search for meaning following a cancer diagnosis. The MMI varied from 1–4 intervention sessions of 30–90 min (individualized to respect the patient’s psychological and physical capacity to address issues) with a therapist promoting self-exploration

Control:  Usual care (n=12).
Compared to the control group, patients in the experimental group had a better sense of meaning (FACIT-Sp-12 Meaning subscale) in life at one and three months post-intervention.

Stress reduction interventions, including yoga, mindfulness, meditation and cognitive-behavioural stress management

The aim of some stress-reduction interventions is to enable people to better manage different stressors by helping them develop a conscious awareness (i.e. mindfulness) of their behaviour, emotions and responses in a non-judgemental and accepting manner.27 These and other stress-reduction interventions may include elements of relaxation to reduce psychosocial stress.186 Examples of practices incorporating mindfulness and/or relaxation include meditation, cognitive-behavioural stress management and yoga.

The 10 studies in which a type of stress-reduction intervention was trialled varied in nature and modality. In nine of the studies, significant effects were found on at least one outcome measure relating to spirituality. In particular, in four studies27, 28-30 significant effects were reported for spiritual wellbeing, while in one study no effect was found.186 In four studies there was a significant effect for benefit finding.31,32,33,34 In one study a significant effect for meaning/peace35 was described and in another a significant effect for meaningfulness and comprehensibility (sense of coherence [SOC])28 was found. The maintenance of each of these effects in patients varied.

The results suggest that stress-reduction interventions are a promising way of enhancing spiritual wellbeing and meaning/benefit finding.

In Table 3, stress-reduction interventions demonstrating significant changes of at least one of the measured outcomes of suffering in the intervention group are listed.

See the systematic review for full details of assessed studies.2

Table 3: Summary of stress reduction intervention studies reporting significant findings in the intervention group measuring outcomes of suffering

Study Intervention and control Outcome

Antoni (2001)32

USA

Study type
RCT

Level of Evidence
Level II

Quality
Strong

Measures
Results measured using a 17-item Benefit Finding scale, and an Emotional Processing item (both developed for this study), Profile of Mood States (POMS), Centre for Epidemiological Study – Depression (CES-D), Impact of Events Scale (IES), Life Orientation Test – Revised (LOT-R).

Patients with early breast cancer completed a cognitive-behavioural stress management group intervention. Sessions included relaxation training and strategies to cope better with cancer-related stress, increase confidence and express emotions.

The intervention consisted of ten weekly 2-hour sessions.

Control: One condensed (5-hour) stress reduction seminar.

Intervention and control had similar reports of benefit finding at baseline but intervention group had significantly higher benefit finding scores at 3-month follow-up, but this had faded by 9 months.

Antoni (2006)34
USA

Study type
RCT

Level of Evidence
Level II

Quality
Strong

Measures
Results measured using a 17-item Benefit Finding scale, Sickness Impact Profile, Positive States of Mind (PSOM), Affects Balance Scale (ABS), and Measure of Current Status (MOCS).

As above and also including some non-early stage but non-metastatic breast cancer patients (N=92). A significant effect for benefit finding in the intervention group that was sustained over time.

Henderson (2012)28
USA

Study type
RCT

Level of evidence
Level II

Quality
Strong

Measures
Sense of Coherence (SOC), Functional Assessment of Cancer Therapy (FACT-B) including spiritual items, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Symptom Checklist 90 Revised (SCL-90-R), Rosenberg Self-Esteem Scale, UCLA Loneliness Scale, Mental Adjustment to Cancer Scale (Mini-MAC), Courtauld Emotional Control Scale (CEC)

Early breast cancer patients received mindfulness-based stress reduction intervention that included meditation and yoga (n=53).

The intervention consisted of  seven 3-hour sessions and full-day silent retreat over 8 weeks, plus three 2-hour booster sessions over three months.

Control: 1) Usual care with monthly supportive phone calls (n=58), or

2) Group nutrition education intervention including group cooking and counselling (n= 52).

Improvements from baseline in the spirituality subscale of FACT-B, resulting in large differences from both control groups, including more active cognitive coping. Other contrasts that were significantly better than both control groups included meaningfulness, anxiety and emotional control. Significant differences in spirituality outcomes were maintained at 12 months between intervention and control groups, but other benefits were not maintained.

Penedo (2006)33
USA

Study type
RCT

Level of evidence
Level II

Quality
Strong

Measures

Benefit Finding Scale from the Positive Contributions Scale - Cancer, Charlson Comorbidities Index, Measure of Current Status, and Functional Assessment of Cancer Therapy – General (FACT-G)

Early prostate cancer patients participated in a group cognitive-behavioural stress management intervention (n=133). The intervention consisted of ten 2-hourly weekly sessions on prostate cancer and treatment, stress management and relaxation skills, and share experiences, with the aim of improving benefit finding and quality of life.

Control: Half-day educational seminar(n=100).

Intervention group experienced significant increases in benefit finding while control did not change significantly. Quality of life was also positively associated with the intervention.

Witek-Janusek (2008)27

USA

Study type
Non-randomised experimental trial

Level of evidence
Level III-2

Quality
Strong

Measures
Quality of Life Index Cancer Version, Jalowiec Coping Scale (JCS), Mindful Attention Awareness Scale (MAAS), plus immune and cortisol measures.

Early breast cancer patients (n=44)participated in a group mindfulness-based stress reduction intervention.

The intervention consisted of eight 2.5-hourly weekly group sessions plus one full-day session to learn mindfulness, breath awareness, meditation and mindful yoga, with the aim of improving immune function, quality of life and coping skills.

Control: Assessment only control group (n=31) was made up of either cancer patients having usual care or healthy, age-matched women (to provide normative data for immune variables)

Intervention group reported significantly more improvement over time in the psychological-spiritual domain of QOL than the controls. Intervention also reported more improvements in coping effectiveness than controls.

Intervention women also showed improvements in immune function compared to the control.

Garland (2007)29
Canada

Study type
Non-randomised experimental trial

Level of evidence
Level III-2

Quality
Strong

Measures
Functional Assessment of Chronic Illness Therapy – Spiritual Wellbeing (FACIT-SP), Post-Traumatic Growth Inventory-Revised (PTGI-R), Symptoms of Stress Inventory (SOSI), Profile of Mood States (POMS)

Breast cancer (majority) and other cancer patients participated in their choice of either a mindfulness-based stress reduction (MBSR) intervention program (n=79) or a healing arts (HA) program (n=51) with the aim of enhancing spirituality and post-traumatic growth (benefit finding), and decreasing stress and mood disturbance.

MBSR included discussion, meditation and yoga. Eight 1.5-hour group sessions plus one 3-hour silent retreat.

HA included self-discovery and empowerment through creative process (writing, drawing, movement). Six 2-hour weekly group sessions.

Both groups had a significant increase on overall post-traumatic growth (benefit finding). While the MBSR group improved significantly more on measures of spirituality, anxiety, anger, stress and mood disturbance, the HA group remained relatively stable in these domains.

Chandwani(2010)31
USA

Study type
RCT

Level of evidence
Level II

Quality
Strong

Measures
Benefit Finding Scale (BFS), Medical Outcomes Study 36-item (SF-36), Brief Fatigue Inventory (BFI), Pittsburgh Sleep Quality Index (PSQI), Centre for Epidemiologic Studies Depression Scale (CES-D), Speilberger State-Trait Anxiety Inventory, Impact of Events Scale

Breast cancer patients receiving radiotherapy participated in one-on-one yoga sessions with an instructor, focusing on postures, breathing, meditation, and relaxation (n=30).

Patients received up to 12 sessions of 1-hour duration over a six-week period, plus practice at home.

Control: Waitlist (n=31).

Significant differences between intervention and control 3 months after radiotherapy (T4) in benefit finding. Intervention group also reported more intrusive thoughts than control group 1 month after radiotherapy (T3), and a significant positive correlation between intrusive thoughts at T3 and benefit finding at T4.

Intervention group also maintained better QOL throughout treatment and into recovery.

Danhauer (2009)35
USA

Study type
RCT

Level of evidence
Level II

Quality
Strong

Measures
Functional Assessment of Chronic Illness Therapy-Spiritual Wellbeing (FACIT-Sp), SF-12 health survey, Functional Assessment of Cancer Therapy-Breast (FACT-B), FACT-Fatigue, Centre for Epidemiologic Studies Depression Scale (CES-D), Pittsburgh Sleep Quality Inventory (PSQI), Positive and Negative Affect Schedule (PANAS)

Breast cancer patients participated in restorative yoga, a gentle yoga practice focusing on postures, breathing and deep relaxation (n=22).

The intervention consisted of 10 weekly 75-minute group classes.

Control: Waitlist (n=22)

Women with higher negative affect and lower emotional wellbeing at baseline derived greater benefit from participating in intervention than control group with similar baseline levels.

There were significant group effects for the FACIT-Sp peace/meaning subscale favouring the yoga group. Significant group effects were also found in CES-D, PANAS-PA and SF-12 mental health scales for the yoga group. The yoga group also had significant within-group improvements in fatigue.

Moadel (2007)30
USA

Study type
RCT

Level of evidence
Level II

Quality
Strong

Measures

Functional Assessment of Chronic Illness Therapy-Spiritual (FACIT-Sp), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Functional Assessment of Cancer Therapy (QOL), Distressed Mood Index

Breast cancer patients participated in hatha yoga classes focusing on stretches, postures, breathing and meditation (n=108).

The intervention consisted of 12 weekly sessions of 1.5 hours duration plus home practice.

Control: Waitlist (n=56).

Yoga intervention was associated with beneficial QOL outcomes, and control group experienced greater decrease in social wellbeing than intervention.

However, primary analyses of entire sample did not predict improvements in spiritual wellbeing at three-month follow-up (T2).

Secondary regression analyses on a subsample of patients not on chemotherapy showed intervention group was predictive of T2 spiritual wellbeing.


 

Hope-centred interventions

Hope-centred interventions encompass both individual and group interactions designed to instil, enhance and maintain aspects of hope in patients with cancer. Interventions in the systematic review included active participation in individual hope-generating activities and face-to-face group sessions exploring different aspects of hope.

In the three studies evaluating hope-centred interventions significant findings were reported across this intervention category. In one study post-intervention (after one week) improvements were reported in hope (HHI) and existential wellbeing (MQOL) measures, but follow-up assessments were not undertaken.20 In another study designed to enhance hope using the HHI scale, an effect was found two weeks post-intervention (i.e. 10 weeks from baseline), which was maintained at 3, 6, and 9 months.14 In another study designed to enhance hope using the Nowotny Hope Scale (NHS), an effect was found two weeks post-intervention (i.e. 10 weeks from baseline). However, this was not maintained at 8 months.19

Overall, these studies provide evidence suggesting that hope-centred interventions can significantly and positively impact on hope in cancer patients at different stages of the disease trajectory. For example, this effect was found in newly diagnosed patients19 , those experiencing recurrent disease,14 and those receiving palliative care.20

In Table 4, hope-centred intervention studies that have statistically significant changes to at least one of the measured suffering outcomes in the intervention group compared with the control group are described.

See the systematic review for full details of assessed studies.2

Table 4: Summary of hope-centred intervention studies reporting significant findings in the intervention group measuring outcomes of suffering

Study Intervention and control Outcome

Duggleby (2007)20
Canada

Study type
RCT

Level of Evidence
Level II

Quality
Strong

Measures
Herth Hope Index [HHI]) and quality-of-life scores (McGill Quality of Life Questionnaire

[MQOL]), Qualitative Open-Ended Hope Questions and Palliative Performance Scale.

 Terminally ill cancer patients (n=30) participated in a psychosocial supportive intervention called the Living with Hope Program (LWHP)  The intervention consisted of viewing a video on hope and doing one of three hope activities in a one-week period (write letters, collect meaningful items for a hope box, or create an ‘About Me’ collection). Measures were collected at the first visit in the patients’ homes by research assistants and one week later.

Control: Standard care (n=31)

Patients receiving the LWHP hadsignificantly higher hope and quality-of-life scores at visit 2 than the control group. Additionally the majority (61.5%) of patients in the treatment group reported the LWHP increased their hope.




Herth (2000)14
USA

Study type
RCT

Level of Evidence
Level II

Quality
Strong

Measures
The Herth Hope Index (HHI) and the Cancer Rehabilitation and Evaluation Systems, Short Form (CARES-SF) were administered

prior to intervention, immediately after intervention and at 3, 6, and 9-month intervals.

Patients with a first recurrence of cancer (n= 38) received a nursing intervention program (quasi-experimental study) designed to enhance hope and quality of life in patients with a first recurrence

Control: 1)Attention control group (n=37) consisted of informative sessions about cancer and treatments,

Or, 2) the usual treatment (n=40) control group consisted of regular care and hospital follow-up.

Treatment and control groups differed significantly for hope and QOL. Both the level of hope and QOL were significantly increased immediately after intervention and over time (3, 6 and 9 months).

Rustoen (1998)19
Norway

Study type
RCT

 

Level of Evidence
Level II

 

Quality
Strong

Measures
Nowotny Hope Scale, Ferrans and Powers Quality of Life Index and the Cancer Rehabilitation and Evaluation Systems, short form.

Cancer patients (mixed) in the intervention group (n=32) participated in the Learning to Live with Cancer program, a nursing intervention designed to increase hope. The intervention consisted of 8 weekly 2 hour sessions.  

Questionnaires were completed twice prior to the intervention, then two weeks and six months post intervention.

Control: Usual treatment, consisting or regular care and hospital follow-up (n=23 and 41).

Level of hope was significantly increased for members of the hope group just after the intervention but not 6 months afterwards. Despite patients’ positive evaluation of the intervention, there was no impact on quality of life.

Supportive-expressive interventions

Supportive-expressive approaches encompass both supportive group and individual therapy designed to enhance overall QOL.98 Interventions include telephone therapy, forgiveness therapy, face-to-face, telephone and internet-based support groups. Interventions may target individual patients or both patients and their partners or caregivers.

Of the five supportive-expressive interventions, there was only one study in which a significant effect on hope (HHI) was found immediately post-intervention.26

Because of the strong variation between the aims and modalities of the included studies, no accurate conclusions could be drawn regarding the impact of supportive-expressive therapies on variables such as hope, spiritual wellbeing, self-transcendence and purpose in life.

In Table 6, supportive-expressive intervention studies with statistically significant changes to at least one of the measured suffering outcomes in the intervention group compared with the control group are described.

See the systematic review for full details of assessed studies.

Table 5: Summary of supportive-expressive intervention studies reporting significant findings in the intervention group measuring outcomes of suffering

Study Intervention and control Outcome

Hansen (2009)26
USA

Study type
RCT

 

Level of Evidence
Level II

Quality
Good

Measures
Herth Hope Index, State Anger Scale, and the McGill Quality of Life Scale.

Elderly terminally ill cancer patients (n=10) completed a four week forgiveness therapy (60 minute once a week individual sessions) in improving the quality of life of elderly terminally ill cancer patients.

All participants completed instruments measuring forgiveness, hope, quality of life, and anger at pre-test, post-test 1 and post-test 2 delivered by a psychologist.

Control: The wait-list control group (n=10) received forgiveness therapy in the second four week period.

Forgiveness therapy group showed greater improvement than the control group on all measures.

After receiving forgiveness therapy, participants in both forgiveness treatment conditions demonstrated significant improvements on all measures (forgiveness, hope, quality of life, and anger reduction).

Spiritual interventions

The aim of spiritual interventions is to address the spiritual concerns of patients and increase hope, happiness, life satisfaction and mental health,36 and wellbeing, coping ability and quality of life.187

These interventions may take the form of multidisciplinary educational sessions, support groups, body-mind-spirit therapy, spiritual counselling, and a brief semi-structured inquiry into religious/spiritual concerns.

In three of the five spiritual interventions, significant findings were reported for aspects of suffering: in an Islamic spiritual education intervention significant effects were reported for hope;36 in a multidisciplinary educational session addressing the five QOL domains including spirituality, significant effects were found for spiritual wellbeing four weeks after baseline on one of the measures (LASA) although not on another (FACIT-Sp total);37 and in a study on a body-mind-spirit therapy intervention, a significant effect was found on the search for meaning subscale component of the Meaning in Life scale.38 However, overall results of these studies are inconsistent, particularly in regards to spiritual wellbeing.

A Cochrane review of spiritual and religious interventions for the wellbeing of adults in the terminal phase of disease,187 which was not included in the systematic review, also found inconclusive evidence that interventions with spiritual or religious components enhance wellbeing. However, only two cancer-related studies were assessed.

One, an interdisciplinary palliative care service that included counselling and attendance by a palliative care physician, palliative care nurse, social worker and chaplain, found no difference between the intervention and usual care groups for physical, emotional/relationship, spiritual and QOL scales. However, the intervention group demonstrated higher patient satisfaction, reduced ICU admissions and lower total health costs.188

A study that compared massage with guided meditation or friendly visits in terminally ill patients initially found no difference between interventions, but on reanalysis using other methods, determined that massage may offer benefits over the other interventions.189, 190

In Table 7, spiritual intervention studies with statistically significant changes to at least one of the measured suffering outcomes in the intervention group compared with the control group are described.

See the systematic review for full details of assessed studies.2

Table 6: Summary of spiritual intervention studies reporting significant findings in the intervention group measuring outcomes of suffering

Study Intervention and control Outcome

Fallah (2011)36
Iran

Study type
Non-randomised, experimental trial

Level of Evidence
Level III-2

Quality
Adequate

Measures

Adult Dispositional Hope Scale (Snyder's Hope scale), Satisfaction with Life Scale, Oxford Happiness Revised Scale and

Spiritual Experience Scale.

Breast cancer survivors were voluntarily assigned into case (n=30) and control groups (n=30) to assess the effectiveness of an Islamic perspective spiritual intervention on the increase of hope, life satisfaction and happiness through eight weekly sessions of 1.5 hours.

Women were assessed before and after using spiritual experience, hope, happiness and life satisfaction questionnaires.

Control: No exposure to Islamic perspective spiritual intervention (n=30).

The spiritual intervention resulted in significant increase of hope, happiness and life satisfaction in the case group women suffering from breast cancer compared to the control group.

Hsiao (2012)38
Taiwan

Study type
RCT

Level of Evidence
Level II

Quality
Strong

Measures
Beck Depression Inventory-II (BDI-II), and the Meaning in Life questionnaire (MLQ) including subscales MLQ-Presence and MLQ-Search.

Breast cancer patients who completed active cancer treatment received eight weekly body-mind-spirit (BMS) group therapy sessions lasting two hours (n=26)

Control: Interpersonal education sessions on health behaviours (n=22).

Greater MLQ Search scores were found in the BMS group compared to the EDU group during fifth month of follow-up. However this effect was not reported for MLQ-Presence scores.

Rummans (2006)37
USA

Study type
Randomised controlled trial

 

Level of Evidence
Level II

 

Quality
Strong

Measures
Single-item linear analog scale (Linear Analog Scale of Assessment or modified Spitzer Uniscale).

Secondary outcome measures Symptom Distress Scale, the Profile of Mood States (POMS) – Short Form and the FACIT-Sp scale.

Radiation therapy patients with advanced cancer and an estimated 5-year survival rate of 0% to 50% (n=55) participated in eight 90-minute sessions that included physical exercises, educational information, cognitive behavioural therapy to increase coping, and group discussion. QOL was assessed at baseline, week 4 (end of intervention), week 8, and week 27.

Control: Standard medical care (oncology specialist referral and cancer support groups) (n58).

Overall QOL at week 4 was maintained by the patients in the intervention whereas QOL significantly decreased for patients in the control group at this time point.

Intervention participants maintained their

QOL, and controls gradually returned to baseline by the end of the 6-month follow-up period.

Other interventions

Interventions encompass music therapy, art therapy, a creative arts study involving a mixture of movement to music, writing and drawing; expressive writing, assessing the impact of systematic assessment of patients, one animal assisted activity study (e.g. dog visits) and one hypnotherapy (i.e. touch) study.

In seven studies that were evaluations of ‘other’ interventions no significant outcomes were reported for suffering outcomes.

In two studies29, 191 an effect was not found for spiritual wellbeing (FACIT-Sp total). In a further study an effect was not found for peace/meaning (FACIT-Sp).192 In yet another study no effect was found for spirituality (ESI-R, including an existential wellbeing dimension).193 Furthermore, no effect on sense of coherence (SOC)194 or meaning in life (HDI)195) was reported in two other studies and neither for spiritual needs (SNI).196

There is therefore no systematic evidence of a positive impact on outcome variables of relevance to this review for any of these interventions, including music therapy; art therapy; creative arts (involving a mixture of movement to music, writing and drawing); expressive writing; systematic assessment of patients; animal assisted activity; and hypnotherapy.

See the systematic review for full details of assessed studies.2

Although the current evidence to support the use of the described interventions for alleviating suffering is limited or weak, a number of hospitals in Australia provide these types of therapies with the aim of assisting patients in stress reduction and emotional expression.

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