A comprehensive meta-analysis found that cognitive behavioral therapy demonstrated statistically significant efficacy in improving both mental health and quality-of-life outcomes for individuals diagnosed with cancer.
The study, published in Cancer Medicine, analyzed data from 132 clinical trials comprising 1,030 effect size estimates and a total sample of 13,226 participants, spanning nearly four decades of research from 1986 to 2023.
Key Findings
- Cognitive behavioral therapy (CBT) showed an overall small to moderate and statistically significant treatment effect size for cancer survivors' mental health and quality-of-life outcomes (d = 0.388, 95% confidence interval [CI] = 0.294-0.483, P < .001).
- Subgroup analysis revealed a moderate effect size for mental health outcomes (d = 0.406, 95% CI = 0.299-0.512, P < .001) and a small effect size for quality-of-life outcomes (d = 0.254, 95% CI = 0.14-0.368, P < .001).
- Age significantly moderated CBT's treatment effect, with younger patients showing greater benefit (b = -0.011, 95% CI = -0.022 to -0.001, P = .037).
- CBT efficacy varied by delivery format, with in-person and mixed in-person/technology approaches showing significant benefits.
Methods
The researchers conducted a systematic review and meta-analysis following PRISMA guidelines. They searched 11 electronic databases and 4 professional websites, including both randomized (n = 122) and nonrandomized (n = 10) controlled trials. The primary outcomes were cancer survivors' mental health and quality of life.
Data analysis utilized meta-regression with robust variance estimation using R Statistical Software (version 4.2.2) and the robumeta package. Effect sizes were calculated using Hedges' g. Subgroup and moderator analyses examined the impact of age and delivery format on CBT efficacy.
Results
The study found that CBT had a statistically significant effect on both mental health and quality-of-life outcomes across a population of cancer survivors. However, the effect was stronger for mental health (d = 0.406) compared to quality of life (d = 0.254).
Age emerged as a significant moderator of CBT efficacy. Subgroup analysis revealed large and statistically significant treatment effects for pediatric, adolescent, and young adult cancer survivors (< 40 years old, d = 0.773, P = .015) and moderate effects for middle-aged adults (40-64 years old, d = 0.384, P < .001). However, the treatment effect was not statistically significant for older cancer survivors (≥ 65 years old, d = 0.092, P = .245).
Delivery format also influenced CBT efficacy. In-person therapy (d = 0.391, P < .001), mixed in-person and technology approaches (d = 0.307, P = .001), and preprogrammed technology-only interventions (d = 0.483, P = .002) all showed statistically significant effects. However, technology-only interpersonal delivery and combined technology-only interpersonal and preprogrammed approaches did not demonstrate statistically significant effects.
Participant Demographics and Study Characteristics
The study included a diverse range of patients with cancer, with an average age of 53.38 years (range = 4.2–76 years) across 129 trials. The majority of participants were female (78.85%, n = 10,303) in the 131 trials reporting sex distribution.
Intervention modalities varied, with 51.59% (n = 65) using individual-based approaches, 42.06% (n = 53) employing small group–based techniques, and the remainder utilizing family-based, couple-based, or combined approaches. Training protocols were implemented in 56% (n = 70) of the trials, and 53.97% (n = 68) incorporated supervision during the intervention.
Regarding patient treatment phase, of the 116 trials documenting this factor, 41.67% (n = 55) included patients undergoing current curative treatment, 32.76% (n = 38) were in post-treatment survivorship, and 12.93% (n = 15) were in a mixed phase.
Risk of Bias and Publication Bias
The study demonstrated a low risk of bias in most areas, including selection of reported results (129/132), measurement of outcomes (126/132), and deviations from intended interventions (122/132). A funnel plot and sensitivity analysis using a priori weight functions were conducted to assess publication bias.
Limitations
The authors noted several limitations, including potential missed articles despite comprehensive search strategies, possible overlooked factors for subgroup and moderator analyses, and the use of univariate moderator analysis due to missing data concerns.
Conclusions
The study authors concluded, "In this study, we noted a mild to moderate improvement in mental health and quality of life in cancer patients receiving CBT as a form of treatment. Additionally, we found that age and treatment delivery setting can influence the efficacy of CBT in cancer patients. These results have implications in effectively treating the psychosocial complications associated with cancer treatment. Further work will need to be performed investigating other factors involved in CBT treatment in cancer patients."
The authors declared having no competing interests.