The efficacy of interventions to improve psychosocial outcomes following surgical treatment for

breast cancer: a systematic review and meta-analysis.

Hannah June Matthews (Corresponding Author) - matthe94@uni.coventry.ac.uk

Coventry University
Faculty of Health & Life Sciences
Priory Street
Coventry
United Kingdom
CV1 5FB

Elizabeth A. Grunfeld - ab7505@coventry.ac.uk

Coventry University
Faculty of Health and Life Sciences
Coventry
United Kingdom

Andrew Turner - hsx116@coventry.ac.uk

Coventry University
Faculty of Health & Life Sciences
Coventry
United Kingdom

The efficacy of interventions to improve psychosocial outcomes following surgical treatment

for breast cancer: a systematic review and meta-analysis.

Key words: cancer, oncology, breast cancer, meta-analysis, mastectomy, and psychosocial
interventions.

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1002/pon.4199

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Abstract

Objective: Breast cancer is the most commonly diagnosed cancer in women across the world.
The majority of women diagnosed with the disease undergo surgery, which is often
associated with significant psychosocial morbidity. The aim of this meta-analysis was to
identify the efficacy of psychosocial interventions for women following breast cancer
surgery.

Method: A comprehensive literature search was undertaken using keyword and subject
headings within seven databases. Included studies employed a quantitative methodology
presenting empirical findings focusing on interventions for female breast cancer patients
following surgery.

Results: 32 studies were included and based on conventional values of effect sizes, small
effects emerged for the efficacy of psychosocial interventions in relation to anxiety (Hedges
g=0.31), depression (0.38), quality of life (0.40), mood disturbance (0.31), distress (0.27),
body image (0.40), self-esteem (0.35), and sexual functioning (0.22). A moderate to large
effect emerged for the efficacy of interventions in promoting improvements in sleep
disturbance (0.67). Clear evidence emerged for the efficacy of cognitive behavioural therapy
in promoting improvements in anxiety, depression and quality of life.

Conclusion: This is the first meta-analysis to demonstrate the efficacy of interventions on a

range of psychosocial outcomes following breast cancer surgery. The meta-analysis
highlighted cognitive behavioural therapy was consistently the most effective psychosocial
intervention promoting improvements in anxiety, depression and quality of life. However,
there are shortcomings in existing studies, the length of the follow-up period is typically short
and the generalisability of findings was limited by small samples, both of which should be
addressed in future studies.

(250 words)

Introduction

Breast cancer is the most commonly diagnosed cancer in women across the world [1]. It is
estimated that one out of every eight women will develop breast cancer at some point in their
lives [2]. Mortality rates have fallen over recent decades partly due to advances in early
detection and treatment [3] resulting in a growing cohort of breast cancer survivors [4].
Improved survival rates have placed increased importance on promoting and supporting a
high quality of life and optimal psychosocial adjustment among breast cancer patients. The
primary treatment for breast cancer is surgical consisting of either a mastectomy or breast
conservation surgery [1]. Following mastectomy approximately one third of women choose
to undergo immediate breast reconstruction [5] in order to reconstruct or reshape the breast
mound.

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Breast cancer diagnosis and treatment is associated with increased rates of anxiety,
depression, distress and reduced quality of life [6]. The period following breast cancer
surgery is also associated with considerable psychosocial morbidity [7] with as many as 30%
of women experiencing anxiety and depression [6]. Body image issues and sexual difficulties
are also significantly higher following surgical treatment for breast cancer [8]. However, it is
often assumed that the distress experienced by women with breast cancer abates after the
initial treatment, yet stress-related symptoms may actually increase after surgery and
treatment completion, as patients leave the safety net provided by contact with the
oncology team [7]. A recent meta-analysis suggested anxiety after a diagnosis of cancer
may persists for up to 10 years or more [9]. Collectively, these findings underscore the
need to address the psychosocial wellbeing of breast cancer patients following surgical
treatment and reconstruction.

The past decade has seen an increase in the development of interventions to reduce
psychosocial morbidity and improve coping and adjustment following breast cancer
treatment. 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 [10].
Psychosocial interventions that have been utilised with breast cancer patients following
surgery include group therapy, individual counselling, psychotherapy, and psychoeducational
interventions [11, 12]. Generally, such interventions have only focused on a limited number
of patient outcomes, including anxiety, depression, and quality of life. Nevertheless,
accumulating evidence indicates psychosocial interventions provide a consistent
beneficial effect for cancer patients [13] and specifically breast cancer patients [11].
However, little is known about which intervention is most effective following breast
cancer surgery. The aim of this systematic review and meta-analysis was to evaluate the
efficacy of interventions on a range of psychosocial outcomes following surgical treatment
for breast cancer, both mastectomy and breast conservation surgery.

Methods

Search, selection and review strategies

Two chartered health psychologists, a medical librarian and a consultant plastic

surgeon formed part of the panel to develop an appropriate search strategy. Four
methods were used to identify relevant studies: a keyword search, a subject search, a
backward search and a forward search. Literature searches were performed using seven
electronic databases: PsycINFO (1976-2015), CINAHL (1998-2015), MEDLINE (1975-
2015), Academic Search Complete (1980-2015), AMED (1996-2014), Cochrane Library
(1975-2015) and EMBASE (1974-2015). The search terms were grouped into three blocks:
Block 1 - breast neoplasms, breast oncol*, breast cancer, breast tumor, breast tumour; Block
2; mastectom* lumpectom*, prophylactic; Block 3 - family therap* group therap*,
psychosocial rehabilitation, anxiety management, relaxation therap*, cognitive therap*,

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cognitive behaviour*, therap*, social support, support groups, counsel*, counselling,
counselling, group counsel, group counselling, and group counselling. The terms relating to
the types of surgical procedures (Block 2) were combined with OR and NOT prophylactic,
referring to prophylactic mastectomy. Terms within each block were combined using OR,
then the results of each block were combined using the AND function. Duplicates were
excluded.This study was approved by a university ethics committee and a review protocol
was developed and followed but is not available to access.

Inclusion criteria were as follows: (i) female adult breast cancer survivors; (ii) any type of
primary breast cancer surgery including mastectomy and breast conservation surgery ;(iii)
psychological, psycho-educational and/or psychosocial intervention; (iv) written in English;
(v) quantitative methodology; (vi) presenting empirical findings. Studies were excluded if
interventions focused on physical rehabilitation, physiological outcomes, palliative and/or
metastatic breast cancer, were published as a conference abstract or a case study. A backward
(reference) search was performed which involved hand searching the reference list of articles
included in the analysis. A forward (citation) search was also performed using Scopus.
Additionally, as part of the systematic search procedure, review articles were also
obtained and examined in order to identify any additional articles.

Two blinded raters (HM & EG) independently applied a 14 item quality assessment
checklist from a standardised quality assessment tool to each study [14]. Discrepancies
were systematically resolved by consensus. Each study was assessed against the 14 items
using a three point scale (2-fully met criterion, 1-partially met and 0-did not meet the
criterion). A total score was calculated by summing the number of yes responses,
multiplying this by 2 and adding this to the number of partials. If a criterion was not
applicable it was excluded from the score calculation. The total possible score was calculated
as 28 minus 2 times the number of not applicable. Lastly, a summary score (total sum/total
possible sum) was calculated representing the methodological quality of each article. These
scores were calculated as a linear score from 0-100 and divided into three categories
representing low, moderate, or high quality studies. Studies with a score of 75 or more were
considered high quality, moderate quality 50-74, and low quality 49 or less.

Meta-analysis strategy

We used hedges g as the effect size statistic. Hedges g calculates the difference between
intervention and control group means (d) divided by the pooled standard deviation (SD)
multiplied by factor (J) that corrects the underestimation of the population SD [15]. Through
pooling variances, hedges g standardises outcomes across studies and allows for
comparison among disparate outcome measures. Effect size calculations used a random
effects model. This assumes that analysed studies represent a random sample of effect
sizes, subsequently facilitating the generalisability of results [16]. The heterogeneity
between studies was calculated using the heterogeneity I2 statistic. The I2 statistic
calculates what proportion (0-100%) of the observed variance reflects variance in true
effect sizes, rather than sampling error. A value of 0% represents no observed
heterogeneity, an I2 value of 25%, 50%, and 75% tentatively signify low, moderate, and

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high heterogeneity between studies [17]. To minimise heterogeneity, when studies reported
outcomes at multiple time points, the furthest time point was used to calculate effect size. We
used the conventional values of effect size [18] in this analysis. An effect size of 0.2
demonstrated a small effect, 0.5 a moderate effect, and 0.8 a large effect. We used the
Comprehensive Meta-Analysis software for all statistical analyses [19].

Sources of bias

Mean effects for each outcome were assessed for the degree of publication bias (the
preferential publication of studies with positive effects). Publication bias was assessed
using two techniques: the examination of the funnel plot and estimates of correction,
trim and fill. If the points on the funnel plot are evenly distributed between positive and
negative effects, bias is lacking within the meta-analysis. If publication bias existis a
disproportionate number of studies will fall to the bottom right of the plot [20]. The
trim and fill method attempts to estimate the number of missing studies that may exist
in the meta-analysis and correct for funnel plot asymmetry [20]. Orwins fail-safe N was
also calculated to assess the roboustness of the overall effect [21]. This will determine
the number of studies with a null effect size required to reduce the overall effect to non-
signficiance. In this meta-analysis the number of studies is represented by k.

Systematic review results

The search strategy identified 3,817 records, reduced to 1,455 unique articles following the
exclusion of duplicates and to 19 articles following the application of the inclusion and
exclusion criteria (Figure 1). A backwards search identified 8 additional articles and a
forward search identified 7 further articles, totalling 34 articles. Twenty-one articles were
classified as high quality, eleven as moderate quality and two as low quality (Table 1). The
two low quality articles were removed from the review. In total, 32 articles were included in
the review. Twenty-two studies utilised a randomised controlled trial design, 5 pre and post
group evaluations, 2 non-randomised controlled studies, 2 single cohort pre & post
evaluations, and 1 randomised & comparative study design. Follow-up periods ranged from 1
to 36 months with between two and six data collection points.

Insert Figure 1. Flow diagram depicting the systematic review process

Participant and design characteristics of the 32 studies included in this review are
summarised in Table 1, and outcome and assessment measures are described in detail in
Table 3, assessiable as online supplementary materials. This review comprised of 32
psychosocial interventions with eight studies utilising cognitive behavioural therapy
interventions [10, 22, 23, 24, 25, 26, 27, 28], seven psychoeducational interventions [29, 30,
31, 32, 33, 34, 35], four support groups [36, 37, 38, 39], three counselling interventions [40,
41, 42], two mindfulness based stress reduction interventions [43, 44], two supportive
expressive group therapy interventions [45, 46], one psychosexual intervention [47],one
music therapy and progressive muscle relaxation training [48] and one contemplative self-
healing intervention [49]. The review also included two studies which combined
psychoeducational interventions and peer and social support interventions [50, 51] and one

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intervention which combined cognitive behavioural therapy, social support and
psychoeducational elements [52]. Twenty-five interventions were delivered in-person, six
interventions were delivered via telephone and one intervention via videoconferencing. The
number of intervention sessions ranged from a single session to 30 sessions. The studies
reported sample sizes ranging from 20 to 442, and the total number of participants across all
studies included in this review was 4,148. Twenty-nine of 32 studies reported significant
treatment effects in one or more examined outcomes.

Insert Table 1. Systematic review of psychosocial interventions for women after breast cancer
surgery (k=32)

Anxiety

Eight of thirteen studies reported a significant reduction in anxiety following the intervention
[23, 27, 39, 44, 45, 46, 47, 48]. Whilst, two studies demonstrated significant effects with
cognitive behavioural therapy on anxiety [23, 27], two studies reported no significant effects
with cognitive behavioural therapy [10, 26]. Counselling interventions also failed to
demonstrate significant treatment effects on anxiety [32, 40, 42]. Moreover, Kimman and
colleagues [32] reported no significant treatment effects of a telephone educational
intervention on anxiety.

Depression

Thirteen studies reported a significant reduction in depression across a range of interventions

including cognitive behavioural therapy [22, 25, 26, 27] psycho-educational intervention
[30], counselling [40], supportiveexpressive group therapy [45, 46], videoconferencing
support groups [36], psychosexual intervention [47], mindfulness based stress reduction [44],
support groups [39],and music therapy & progressive muscle relaxation training [48]. No
significant treatment effect was reported for telephone counselling [41], psycho-education
and peer modelling on depression [35].

Quality of life

Thirteen studies reported improved quality of life across a range of interventions including,
contemplative self-healing intervention [49], psychoeducational interventions [31],
mindfulness based stress reduction [43], cognitive behavioural therapy [34, 25, 26, 27, 42],
and combined interventions utilising psychoeducational, cognitive behavioural therapy and
social support [3] and a psychoeducational and peer support intervention [50].Support
groups [37], and two psychoeducational interventions [32, 33] reported no significant
treatment effects on quality of life.

Mood disturbance

Five studies reported a significant improvement in mood with supportiveexpressive group

therapy [45, 46], mindfulness based stress reduction [43], telephone cognitive behavioural
therapy [10], and counselling [42]. In contrast, two psychoeducational interventions reported
no significant treatment effect on mood disturbance [29, 51].

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Distress

In two psycho-educational interventions [29, 35], and a telephone counselling intervention

[41] no significant treatment effect was demonstrated in lowering distress. In contrast, there
were modest improvements in distress after cognitive behavioural therapy [22], a support
group intervention [38] and a relaxation intervention [24] all reported a significant reduction
in distress. However, one psychoeducational intervention reported an increase in distress post
intervention [29].

Body image

Two studies reported significant treatment effects with cognitive behavioural therapy [24],
and support groups [37]. In contrast, no significant treatment effect on body image was
observed for supportive expressive group therapy [46].

Sleep disturbance

Two studies reported improved sleep utilising supportive expressive group therapy [46], and
cognitive behavioural therapy [27]. One study reported a reduction in sleep disturbance was
associated with decreased anxiety, depression and improved global quality of life [31].

Self-esteem

Group cognitive behavioural therapy reported a significant improvement in self-esteem [26,

28]. In contrast, studies utilising support groups [38] and couple counselling [40] reported no
significant treatment effects for self-esteem.

Sexual functioning

Two studies reported significant improvements in sexual dysfunction through counselling

[40, 41]. The control group showed virtually no change from baseline, suggesting that this
source of psychosocial morbidity may be especially resistant to improvement in the absence
of intervention [41]. However, Esplen and colleagues [37] reported no significant treatment
effects with support groups and sexual functioning.

Meta-analysis results

Weighted average effect sizes for each outcome are displayed in Table 2 and forest plots
are displayed in Figure 2. Additionally, Table 2 details results of analyses to detect
publication bias and heterogeneity statistics for each of the psychosocial outcomes.
Meta-regression indicated that the number of sessions within a intervention was not a
significant moderator of depression (k=10;B=0.006;P=0.49), nor was quality of life
(k=11;B=-0.016;P =0.08). However, the number of sessions was a significant moderator
for anxiety (k=9;B=0.015; P=0.04). In regards to publication bias, all funnel plots
displayed a greater number of studies to the right of the mean. However, as a
disproportionate number of studies did not fall to the bottom right of the plot, this
suggests systematic bias does not significantly contribute to our estimate of the efficacy
of interventions in relation to psychosocial outcomes. Funnel plots are displayed in

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Figure 3, acessiable online via supplementary materials. Trim and fill procedures
inputed 5 studies for depression, 1 study for anxiety, 4 studies for quality of life and
body image, 1 study for sexual functioning, 2 studies for mood disturbance and ditress,
and no studies were inputed for self-esteem. Orwins fail-safe N was calculated in order
to assess the robustness of the overall effect for each outcome. Orwins fail-safe N
indicated 198 non-significant studies for depression, 81 for anxiety and 189 for quality
of life would be required to render the efficacy of the interventions trivial. Orwins fail-
safe N analysis for all outcomes are displayed in Table 2.

Insert Table 2. Mean effect sizes for psychosocial outcomes for studies with sufficient data
for the meta-analysis.

Insert Figure 2. Forest plots of effect sizes for studies assessing psychosocial outcomes.

Discussion

To our knowledge, this is the first meta-analysis to evaluate the efficacy of interventions on a
range of psychosocial outcomes in breast cancer patients. The meta-analysis demonstrated
small effect sizes on eight psychosocial outcomes: anxiety, depression, quality of life,
mood disturbance, distress, body image, self-esteem, and sexual functioning. A
moderate to large effect size was detected on sleep disturbance. Within this meta-analysis
anxiety (k=14), depression (k=14) and quality of life (k=13) were the most commonly
reported outcomes. This is not surprising given the high incidence of anxiety and depression
after surgical treatment for breast cancer, with as many as 30% of women reporting to
experience anxiety and depression [6], and the widely recognised impact of anxiety and
depression on quality of life [7]. Moreover, cognitive behavioural therapy was the most
common intervention for both anxiety and depression, often reporting significant treatment
effects [22, 23, 25, 26, 27]. This meta-analysis provides clear evidence for the efficacy of
cognitive behavioural therapy in improving outcomes in relation to anxiety [10, 23, 37, 39],
depression [22, 25, 26, 37], and quality of life [25, 26, 27, 28]. Meta-regression indicated
the number of sessions was not a significant moderator of depression or quality of life,
although we can conclude the number of sessions is related to effect size for the outcome
anxiety. However, we cannot conclude if the length of the sessions moderated the effect
size, nor the timing of the intervention or who delivered the intervention, as a large
portiotion of the studies did not report significant details of the interventions. This
should be addressed in future research in order to develop effective evidence based
interventions to enhance breast cancer care.

A previous meta-analysis demonstrated the efficacy of cognitive behavioural therapy

following treatment for adult cancer survivors on anxiety, depression and quality of life with
a large effect size (g=1.99), based on four studies [52]. The findings of this meta-analysis are
conservative yet consistent with previous literature. Moreover, a meta-analysis assessing the
efficacy of psychological interventions for breast cancer patients reported strong treatment
effects for the efficacy of cognitive behavioural therapy improving anxiety, depression, and

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quality of life [53]. This meta-analysis is the first to demonstrate the efficacy of psychosocial
interventions to improve a range of psychosocial outcomes following breast cancer surgery.
Previous literature [52] has predominately focused on anxiety, depression and quality of
life. Whilst these are undoubtedly important outcomes, our meta-analysis goes beyond
this and considers less explored yet emerging research outcomes. However, this meta-
analysis cannot conclude if the time period following breast cancer surgery is optimal to
provide support for breast cancer patients, this warrants further investigation. Moreover, it is
not clear for the other psychosocial outcomes which intervention would be most effective,
this should be addressed in future studies. Consequently, robust conclusions cannot be drawn
surrounding which intervention would be most effective for specific psychosocial outcomes,
with the exception of cognitive behavioural therapy improving outcomes in relation to
anxiety, depression and quality of life.

The quality of both the systematic review and meta-analysis is dependent on the quality of
studies analysed. One review suggests the more rigorous the review the less likely it is to
conclude there is evidence psychosocial interventions in oncology are effective [54].
Consequently, the design of the studies included must be considered. Whilst, the majority of
studies utilised a randomised controlled trial study design, a number of studies employed a
pre and post-test design. Therefore, in the studies which employed a pre and post-test design
the findings may be attributed to changes which occurred independently to the intervention,
for example increased support from family members may improve psychosocial wellbeing. A
number of studies acknowledge an absence in randomisation and/or the process of
randomisation did not result in equity between groups. Therefore, further evidence with
randomised controlled trial study designs may be required to confirm significant treatment
effects are not linked to weaker study design. This meta-analysis did not include
unplublished studies, as we considered published peer-reviewed studies would provide
the strongest evidence regarding the efficacy of psychosocial interventions. However, we
recognise effect sizes may be overestimated with the absence of publication of null
findings. This review also reported both primary and secondary outcomes of studies
within the meta-anlaysis. Subsequently, we acknowledge the possibility of reporting
small effect sizes for secondary outcomes. Seven studies were excluded because the
published data were not suitable for meta-analysis, and the required data could not be
obtained from the authors [11, 23, 25, 37, 39, 44, 48].

The studies included in this meta-analysis present a number of limitations. The majority of
the studies recruited a sample of highly educated, middle class white women who were likely
to be motivated to participate in health research. Furthermore, three studies [26, 30, 45]
utilised samples with clinically depressed and highly distressed participants, another study
included women experiencing chronic insomnia [27]. Consequently a significant
improvement is more likely, as participants who experience considerable psychological
symptoms may be more likely to engage in interventions and hence benefit more from the
intervention, enhancing the likelihood of detecting significant treatment effects [55]. We
recommend that researchers should be aware of the sample when assessing the findings.
Future studies may want to consider screening for psychological symptoms and

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including only those participants with elevated scores. This would allow for resources to
be targeted at those who would benefit most from the intervention and reduce the
likelihood of bias from the ceiling/ floor effects.

Seven studies acknowledged limited generalisability from small sample sizes (n<50), and
hence were underpowered to evaluate changes in the multiple outcomes that were measured
[25, 36, 38, 40, 46, 47, 49]. Notably, studies with low statistical power have a reduced chance
of detecting a true effect [56]. A number of studies also reported limited generalizability from
single centre trials, due to the use of a single highly trained therapist within the interventions.
Furthermore, many of the interventions included multiple components, subsequently it is
often not possible to determine which component an improvement is attributable too. As
Czaja and colleagues [58] acknowledged the decomposition of psychosocial interventions to
identify effective components is an important goal within the field of psycho-oncology and
should be addressed in future studies. Moreover, no studies included in this meta-analysis
evaluated the cost effectiveness of interventions. However, there is a pressing need for
studies to address cost issues for breast cancer interventions to determine if the initinal
intervention cost becomes cost-effective overtime [56]. For example a reduction in the
number of GP visits, may result in overall cost-effectiveness of an intervention [57]. We
recommend future investigators to consider the cost-effectiveness of interventions,
particularly considering different modes of administration (i.e. in-person or over the phone)
in order to provide efficient and cost effective support.

This is the first meta-analysis to evaluate the efficacy of interventions to improve a range of
psychosocial outcomes following breast cancer surgery. This meta-analysis has demonstrated
the efficacy of cognitive behaviour therapy in improving outcomes in relation to anxiety,
depression and quality of life. This meta-analysis is of significant importance given the
potential widespread integration of evidenced-based psychosocial interventions in clinical
cancer care. Future research priorities should focus on strengthening studies both
conceptually and methodologically, in order to meaningfully pool data to determine which
intervention components are required to enhance breast cancer suvivourship. Currently robust
conclusions cannot be determined surrounding the efficacy of different types of psychosocial
interventions. However, this meta-analysis provides a methodical, novel and secure evidence
base for the efficacy of cognitive behavioural therapy on anxiety, depression and quality of
life following breast cancer surgery.

Funding

This research received no specific grant from any funding agency in the public, commericial
or not-for-profit sectors. It was completed as part of a doctoral programme of study.

Conflict of Interest

No conflict of interest has been decalred by the author(s).

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 Searched electronic databases:
PsycINFO, CINAHL,
MEDLINE, Academic Search
Complete, AMED, Cochrane
Library and EMBASE. 3817 Exclusion of unsuitable
Studies obtained studies.
1376 studies were excluded
for the following reasons:
a) Abstract not relevant
Exclusion of duplicates 1455
b) Review paper
Studies.
c) Comparative study
d) Case study
e) Conference or dissertation
Review titles and abstracts of abstract
search results. f) Qualitative methodology
g) Prophylactic mastectomy
interventions.
Obtained full text of relevant
articles.

Review full text of identified

Exclusion of irrelevant
articles.
studies
Inclusion and exclusion criteria 19 studies were included
applied. 42 excluded for these
Backward search reasons:
8 studies obtained a) Full text was not relevant
b) Palliative or metastatic
c) Omission of mastectomy
Forward search patients
7 studies obtained d) Decision aid interventions
e) Rehabilitation or
physiological interventions.
2 low quality studies were
removed

32 studies included in the review

Figure 1. Flow diagram depicting the systematic review process

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Figure 2: Forest plots of effect sizes for studies assessing psychosocial outcomes

Meta-Analysis: Depression

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Ashing 2014 0.40 0.14 0.02 0.12 0.68 2.82 0.00
Christensen 1983 0.90 0.45 0.20 0.02 1.78 1.99 0.05
Classen 2008 0.21 0.11 0.01 0.00 0.42 1.98 0.05
Collie 2007 0.53 0.20 0.04 0.14 0.93 2.66 0.01
Lengacher 2009 0.48 0.22 0.05 0.05 0.91 2.18 0.03
Marchioro 1996 1.17 0.35 0.13 0.48 1.87 3.31 0.00
Marcus 2009 0.22 0.11 0.01 -0.01 0.44 1.88 0.06
Montazeri 2001 0.36 0.14 0.02 0.10 0.63 2.66 0.01
Qui 2013 0.63 0.27 0.07 0.10 1.16 2.34 0.02
Savard 2005 0.53 0.27 0.07 0.01 1.05 2.00 0.05
Stanton 2005 0.01 0.12 0.01 -0.22 0.25 0.12 0.91
Zhou 2015 0.51 0.16 0.02 0.21 0.82 3.30 0.00
0.38 0.07 0.00 0.24 0.52 5.41 0.00
-1.00 -0.50 0.00 0.50 1.00
Decline of outcome Improv ement of outcome

Meta-Analysis: Anxiety

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Antoni 2009 0.35 0.18 0.03 -0.00 0.69 1.95 0.05
Classen 2008 0.26 0.11 0.01 0.06 0.47 2.49 0.01
Fobair 2002 0.55 0.23 0.05 0.09 1.00 2.36 0.02
Kimman 2011 0.01 0.12 0.01 -0.21 0.24 0.10 0.92
Lengacher 2009 0.48 0.22 0.05 0.05 0.92 2.18 0.03
Montazeri 2001 0.29 0.13 0.02 0.03 0.56 2.16 0.03
Qui 2013 0.13 0.26 0.07 -0.37 0.63 0.52 0.60
Sandgren 2000 0.41 0.27 0.08 -0.13 0.95 1.48 0.14
Savard 2005 0.60 0.27 0.07 0.07 1.12 2.23 0.03
Zhou 2014 0.51 0.16 0.02 0.21 0.82 3.30 0.00
0.31 0.06 0.00 0.19 0.43 4.95 0.00
-1.00 -0.50 0.00 0.50 1.00
Decline of outcome Improv ement of outcome

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 Meta-Analysis: Quality of Life

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Charlson 2014 0.39 0.15 0.02 0.09 0.69 2.59 0.01
Cho 2006 0.89 0.28 0.08 0.34 1.44 3.19 0.00
Dow Meneses 2007 0.29 0.13 0.02 0.05 0.54 2.32 0.02
Esplen 2012 0.08 0.15 0.02 -0.22 0.37 0.50 0.62
Hoffman 2012 0.45 0.14 0.02 0.18 0.73 3.29 0.00
Kimman 2011 0.09 0.12 0.01 -0.13 0.32 0.81 0.42
Manos 2008 0.38 0.15 0.02 0.09 0.67 2.58 0.01
Marchioro 1996 0.97 0.35 0.12 0.29 1.65 2.81 0.00
Qui 2013 0.50 0.25 0.06 -0.00 1.00 1.95 0.05
Savard 2005 0.52 0.27 0.07 0.00 1.05 1.97 0.05
Sharif 2006 0.68 0.21 0.04 0.27 1.08 3.30 0.00
Wojtyna 2007 0.61 0.25 0.06 0.12 1.09 2.46 0.01
0.36 0.05 0.00 0.26 0.45 7.26 0.00
-1.00 -0.50 0.00 0.50 1.00

Decline of outcome Increase of Outcome

Meta-Analysis: Body Image

Studyname Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Esplen 2012 0.43 0.17 0.03 0.10 0.76 2.58 0.01
Fadaei 2010 0.62 0.24 0.06 0.15 1.09 2.59 0.01
Fobair 2002 0.15 0.22 0.05 -0.27 0.58 0.72 0.47
0.40 0.12 0.01 0.16 0.63 3.26 0.00

-1.00 -0.50 0.00 0.50 1.00

Decline of outcome Improv ement of outcome

Meta-Analysis: Sleep distrubance

Studyname Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Fobair 2002 0.50 0.23 0.05 0.05 0.95 2.20 0.03
Savard 2005 0.89 0.27 0.08 0.36 1.43 3.26 0.00
0.67 0.19 0.04 0.29 1.05 3.46 0.00

-1.00 -0.50 0.00 0.50 1.00

Decline of outcome Improv ement of outcome

Meta-Analysis: Self-esteem

Studyname Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Gunn 2005 0.09 0.15 0.02 -0.20 0.38 0.58 0.56
Qiu 2013 0.60 0.26 0.07 0.10 1.10 2.34 0.02
Wojtyna 2007 0.51 0.25 0.06 0.03 0.99 2.08 0.04
0.35 0.18 0.03 0.00 0.69 1.97 0.05

-1.00 -0.50 0.00 0.50 1.00

Improv ement of outcome Decline of outcome

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 Meta-Analysis: Mood distrubance

Studyname Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Classen 2008 0.35 0.11 0.01 0.14 0.56 3.29 0.00
Fobair 2002 0.50 0.23 0.05 0.05 0.95 2.20 0.03
Hoffman 2012 0.45 0.14 0.02 0.18 0.73 3.29 0.00
Jones 2011 0.11 0.08 0.01 -0.04 0.26 1.41 0.16
0.31 0.10 0.01 0.12 0.51 3.15 0.00

-1.00 -0.50 0.00 0.50 1.00

Decline of outcome Improv ement of outcome

Meta-Analysis: Distress

Studyname Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper
g error Variance limit limit Z-Value p-Value
Antoni 2001 0.31 0.20 0.04 -0.09 0.70 1.52 0.13
Gunn 2005 0.52 0.16 0.03 0.21 0.83 3.31 0.00
Jones 2013 0.02 0.05 0.00 -0.09 0.12 0.33 0.74
Marcus 2010 0.21 0.11 0.01 -0.02 0.43 1.81 0.07
Sandgren 2000 0.57 0.28 0.08 0.03 1.12 2.06 0.04
0.27 0.11 0.01 0.05 0.49 2.35 0.02

-1.00 -0.50 0.00 0.50 1.00

Decline of outcome Improv ement of outcome

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Authours Study design Sample Intervention Measures Outcomes Quality
size rating
Antoni et RCT Int: 46 Cognitive The Profile of Mood Distress 1.77 F=2.33 High
al. 2001 Comp: 53 behavioural States Depression Int:
USA therapy Center for Optimism Q=13.60**
Epidemiologic Comp:
Studies Depression Q=2.67
Scale Int:2.81
Life Orientation Comp=20.15
TestRevised F=6.96***
Antoni et RCT Int: 63 Cognitive Impact of Event Anxiety F = 3.86* High
al. 2009 Comp: 65 behavioural Scale Intrusive F= 3.24*
USA therapy Hamilton rating scale thoughts
for anxiety
Affects Balance
Scale
Ashing & RCT Int: 100 Psychoeducational 20 item CES-D Depression Int: 25.4 High
Rosales Comp: 99 intervention 17.2***
USA Comp:14.8
14.1*
(CI: -5.75 to -
0.282)*
Charlson et Pre & post Int: 46 Contemplative The Impact of Events QoL 4.6 10.9* High
al. USA group self-healing Scale Spirituality +1.41.0
evaluation intervention General Functional Breast Cancer +4.8 12.8
Assessment of Specific QoL
Cancer Therapy
Scale + Breast
Cancer Subscale
FACIT Spirituality
scale
Cho et al. Non Int: 28 Psychoeducational 18-item Psychosocial Psychosocial Int: 49.1 Moderate
Asia randomised Comp: 27 intervention & adjustment Scale adjustment 52.1***
& Peer support 27-item Quality of Quality of life Comp: 50.3
comparative life Scale 4.73
Int: 6.2 7.0
** Comp: 6.4
6.3
Christensen RCT Int: 10 Couples Locke- Wallace Martial Int: 106.15 Moderate
USA Comp: 10 Counseling Martial Adjustment happiness Comp:99.6
Test Sexual Int: 80.41
Sexual Satisfaction functioning Comp: 69.04
Scale Depression F=33.92*
Beck Depression Self-esteem Int: 98.18
Inventory Anxiety Comp: 12.02
Rosenberg Self- F=7.53*
Esteem Scale Int: 17.5
Spielberger Comp:17.8
State/Trait Anxiety Int: 39.9
Inventory (STAI) Comp:40.5
Classen et RCT Int: 178 Supportive The Profile of Mood Mood Int: 13.69 High
al. USA Comp:179 expressive group States Questionnaire Anixety F=4.7* Comp:
therapy The Hospital Anxiety Depression 9.05 F=6.5***
and Depression Scale Social Int: F=5.4*
Yale Social Support support Comp:
Index F=6.3**
Int:F=5.2*
Comp:F=5.3*
Int:F=6.0*
Comp: 5.4*
Coleman et RCT Int: 54 Psychoeducational Profile of Mood Mood NS High
al. USA Comp: 52 intervention & States Cancer- NS
social support The visual Analogue Related NS
ScaleWorry Worry NS
The Relationship Relationships
Change Scale Loneliness
The 20-item
University of
California, Los
Angeles, Loneliness
ScaleVersion 3

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Collie et al. Pre & post Int: 27 Support groups The Center for Depression t=2.44* Moderate
USA group Epidemiologic Emotional d=0.51
evaluation Studies Depression expression t=0.44
Scale Self-efficacy t=0.71
The Cancer Behavior
Inventory
Courtauld Emotional
Control Scale
Dow RCT Int: 125 Psychoeducational Quality of Life- Quality of Int: -1.687 High
Meneses et Comp: 131 intervention Breast Cancer Life Comp:-
al. USA Survivors 2.909***
Esplen et RCT Int: 128 Support groups Body Image Scale Body Image Int:18.3 15.3 High
al. Comp: 65 Objectified Body Body Stigma Comp:18.5
USA Consciousness Scale Sexual 17.3*
Mental Adjustment to Functioning Int: 37.5
Cancer Scale Quality of 34.3 Comp:
Female Sexual Life 37.5
Function Index 37.4***
Social Support Int:13.5 15.2
Survey Comp: 12.1
Functional 12.7
Assessment of Int: 91.2
Cancer Therapy 94.8 Comp:
Breast 89.8 92.4
Fadaei et RCT Int: 32 Cognitive The body image scale Body Image Int:16.97 Moderate
al. Iran Comp: 40 behavioural (BIS) 9.03 t=-
therapy 6.07***
Comp:15.95
17.18
Fobair et al. Single cohort Int: 20 Supportive The Impact of Event Mood t=-2.43* High
USA pre & post Expressive group Scale Anixety t=-2.52*
evaluation therapy The Profile of Mood Depression t=-3.11**
States Coping t=-3.57**
The Hospital Anxiety Body image t=0.71
and Depression Scale Relationships t=-2.78**
The Mini-Mental Social t=-2.42*
Adjustment to Cancer Support t=-1.62
The Body Image and Impact of t=2.27*
Sexuality Scale for illness on life
Women With Breast Sleep
Cancer
The Family Relations
Index
The Social Network
and Support
Assessment
The Medical
Interaction Scale of
the cancer
rehabilitation
evaluation system
The Impact of Illness
on Your Life
questionnaire
Structured Insomnia
Interview
Gunn et al. Pre & post Int: 44 Support groups Profile of Mood Distress t=3.44*** Moderate
Australia group States Self-esteem t=-0.55
evaluation The Coopersmith Social t=0.77
Self-esteem support
Inventory
The Duke UNC
Functional Social
Support
Questionnaire
Hoffman et RCT Int: 103 Mindfulness Profile of Mood Mood (CI:-21.02 to - High
al. UK Comp: 111 based stress States Quality of 4.81)***
reduction Functional Life (CI:4.16 to
Assessment of Well-being 10.68)***
Cancer Therapy (CI:1.16 to
Breast 3.15)***
WHO five-item well-
being questionnaire

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Jones et al. RCT Int: 216 Psychoeducational Knowledge Knowledge 0.718 High
Canada Comp: 226 intervention questionnaire Precieved (CI:0.418 to
Perceived preparedness 1.017)***
preparedness for re- Self-efficacy 0.409 (CI:
entry scale Mood 0.273 to
Self efficacy for Distress 0.545)***
managing chronic -0.221 (CI:-
disease 0.510 to
Profile of Mood 0.068)
States 0.859 (CI-
Health distress scale 2.398 to
4.116)
0.114 CI-
0.035 to
0.262)
Kalaitzi et RCT Int: 20 Psychosexual Speilberger's State Depression int: <0.001*** Moderate
al. Greece Comp: 20 intervention Trait Anxiety Anxiety Comp:
Inventory (STAI) p<0.236
Centre for int:p<0.006**
Epidmiological Comp:
Studies-Depression p<0.645
Scale (CES-D)
Questionnaire
assessing sexuality
and body image
Kimman et RCT Int: 149 Psychoeducational The EORTC QLQ- QOL NS High
al. Comp:150 intervention C30 Anxiety NS
Netherlands State-Trait Anxiety
Inventory
Kionberg et Non Int: 50 Psychoeducational The functional Wellbeing NS High
al. Sweden randomised Comp: 46 intervention assessment of cancer Sense of NS
controlled therapy general scale Coherence
study (FACT-G)
Sense of Coherence
Scale
Lengacher RCT Int: 41 Mindfulness 30-item Concerns Fear of Int:9.3 High
et al. USA Comp: 43 based stress about Recurrence recurrence Comp:11.6**
reduction Scale State Anxiety Int:28.3
The State-Trait Depression Comp:33.0*
Anxiety Inventory Optimism Int:6.3
Epidemiological Perceived Comp:9.6*
Studies depression stress Int: 46.7
Scale Social Comp: 44.9
6-item Life support Int: 12.6
Orientation Test Comp:14.4
10-item Perceived Int: 12.4
Stress Scale Comp: 12.8
19-items Medical
Outcomes Social
Support Survey
Manos et Non Int:94 Psychoeducational EORTC Quality Of Quality of life F=25.173** Moderate
al. Spain randomised Comp:94 intervention & Life Scale Anxious F=16.036**
controlled cognitive Mental Adjustment to preoccupation F=55.345**
study behavioural Cancer scale. Fighting spirit F=18.413**
therapy & social Optimism
support
Marchioro RCT Int: 18 Cognitive Functional Living Quality of Int: 41.17 Moderate
et al. Italy Comp: 18 behavioural Index Cancer Life Comp:
therapy The Beck Depression Depression 60.28***
Inventory Int: 4.83
Comp:8.17***
Marcus et RCT Int: 152 Counseling Impact of Event Distress p=0.29 r=0.24 High
al. USA Comp: 152 Scale Depression p=0.48 r=0.23
Center for Sexual p=0.04
Epidemiologic fucntioning r=0.23*
Studies Depression
Scale
The Sexual
Dysfunction scale
Montazeri Single cohort Int: 56 Support groups The Hospital Anxiety Anxiety t=2.21* Moderate
et al. Iran pre & post and Depression Scale Depression t=2.75**
evaluation

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Qui et al. RCT Int: 31 Cognitive 17 item Hamilton Depression Int: 7.51 High
China Comp: 31 behavioural Depression Rating Anxiety Comp: 14.35
therpay Scale Self-esteem (ES=1.51)***
Self- Rating Anxiety Quality of life Int: 37.74
Scale Comp: 43.10
Functional (ES=0.66)
Assessment of Int:28.42
Cancer Therapy- Comp: 27.00
Breast (ES=0.63)*
Self-Esteeem Scale Int: 97.17
(SES) Comp: 89.85
(ES=0.53) **
Sandgren et RCT Int: 24 Cognitive Coping Response Int: 8.2 Comp: High
al. USA Comp: 29 behavioural Indices-Revised Distress 7.4 F=4.48*
therapy Profile of Mood Coping Int:28.9
States Cognitive Comp: 26.7
Coping Int: 31.5
Behavioural Comp:20.8
Coping Int:11.2
Avoidant Comp:12.0
Anxiety Int: 2.9 Comp:
Mood 3.6 F=6.29*
Int: 2.0 Comp:
3.0 F=3.15*
Savard et RCT Int: 27 Cognitive Insomnia Severity Sleep F=11.70*** High
al. Canada Comp: 30 behavioural Index Anxiety F=5.19*
therapy Hospital Anxiety and Depression F=4.14*
Depression Scale Quality of F=5.69*
The European Life
Organisation for
Research and
Treatment of Cancer
Quality of Life
Questionnaire
Sharif et al. RCT Int: 49 Psychoeducational EORTC Quality of Quality of Int: 80.0 High
Iran Comp: 50 intervention Life Question Life Comp:
61.66***
Stanton et RCT Int:143 Psychoeducational Four Item Short Vitality Educ: 7.36 High
al. USA Comp: 136 intervention Form Vitality Distress Comp: 6.60
Subscale Depression Educ: -0.07
Revised Impact of Posttramatic Comp:-0.08
Events Scale Growth Educ: -0.68
The Centre for Perceived Comp: -1.79
Epidemiologic preparedness Educ: 5.44
Studies Depression Comp:2.43
Scale B=3.73
Posttramatic Growth (CI:0.95 to
Inventory 6.52) t=2.64**
Perceived
preparedness for
reentry
Watson et Pre & post Int: NR Counselling Profile of Mood Mood Int: t=2.98* Moderate
al. UK group Comp: NR States Anxiety Comp:t=2.3*
evaluation Speilberger State- Int: 0.5
Trait Anixety Comp:4.5
Inventory
Wojtyna et Pre & post Int: 35 Cognitive European Quality of Int: 64.76 Moderate
al. Poland group Comp:32 behavioural Organisation for life Comp:54.86
evaluation therapy Research and Self esteem f=6.33*
Treatment of Cancer Int: 27.06
Questionnaire Comp:32.91
R. Cibor's Self f=4.46*
Esteem Scale
Zhou et al. RCT Int: 85 Music therapy & Zung self-rating Depression 38.29 32.65 High
China Comp:85 progressive depression Scale Anxiety F=6.91**
muscle relaxation State Anxiety 53.98 41.06
training Inventory F=5.46*
p<0.05* p<0.01** p<0.001*** Bold= primary study outcomes

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Table 2. Mean effect sizes for psychosocial outcomes for studies with sufficient data for
the meta-analysis.

Psychosocial k Effect size 95% CI p-value Heterogeneity Fail-safe

outcome (g) N

Depression 12 0.38 0.24- 0.001 Q=21.52, p=0.04, 198

0.52 I2=44.23

Anxiety 10 0.31 0.19- 0.001 Q=12.71 p=0.24, 81

0.43 I2=21.33

Quality of Life 10 0.40 0.27- 0.001 Q=20.48 p=0.04, 189

0.54 I2=46.29

Body Image 3 0.40 0.16- 0.001 Q=21.68 p=0.33, I2=7.74 7

0.63

Sexual functioning 3 0.22 0.07- 0.14 Q=3.63, p=0.16, I2= 2

0.50 44.89

Sleep disturbance 2 0.67 0.29- 0.001 Q=1.19 p=0.27, I2=16.52 N/A

1.05

Self-esteem 3 0.35 0.00- 0.05 Q=4.14 p=0.12, I2=51.71 4

0.69

Mood disturbance 4 0.31 0.12- 0.001 Q=8.95 p=0.06, I2=55.33 35

0.51

Distress 5 0.27 0.05- 0.02 Q=11.41 p=0.01, 9

0.49 I2=73.72

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