Palliative and supportive interventions to improve patient-reported outcomes in rural residents with cancer

Analysis

The articles that met the inclusion criteria were heterogeneous in design and analytic approach. The set of manuscripts identified, therefore, did not meet the statistical assumptions for meta-analytic data analysis. The analytic plan for this review consisted of sorting the results described in the identified articles into meaningful categories, identifying cross cutting themes, and presenting the results of these themes in narrative forms.
 

Results

Study selection

The search strategy resulted in 886 articles across the 4 databases. The breakdown for each database is as follows: PsychINFO (n = 286), PubMed (n = 194), CINHAL (n = 334), Scopus (n = 72). After duplicates were removed, 864 articles were left and were initially screened resulting in 844 articles being excluded. The remaining 20 articles were reviewed and 12 articles failed to meet the inclusion criteria. Reasons for exclusion included: the population was not rural; no advanced cancer in sample; intervention was not specifically palliative care or supportive oncology. Nine articles representing 8 projects (one project published 2 manuscripts included in this review) were included in the final review (Figure).

After reviewing the articles, 2 clear themes arose: PROs, and overall impact of rural palliative care for people and society. The PRO theme included articles that provided information on how an intervention or program improved the personal lives experience of rural cancer patients. PROs, such as decreased symptomology, were often reported. The “overall impact of rural palliative care for people and society” theme included articles that provided information on how an intervention or program improved the lives of rural people and society as a larger group. An example would include results indicating how a program increased access to supportive oncology care in a rural area.
 

Study characteristics

Nine publications, describing 8 projects were included in this review (Table). These projects were conducted in Canada (n = 3)^14-16 Australia (n = 1)¹⁷ and the United States (n = 5).^18-22 All of the the projects used a quantitative approach for the analysis, except 1 that used mixed-methods.¹⁶ The studies designs were: 4 feasibilities/pilot studies, 1 randomized control trials (RCT), and 3 program evaluations.

A total of 807 patients participated across the 9 articles. Participants’ age ranged from 20 to 88 years. The average ages for participants ranged from 50.4 to 70.7 years. Overall, there were slightly more men (55%) than women (45%) when all the demographic data were combined across the 9 articles; however, 2 articles exclusively had women as part of the sample.^17,20 The cancer types that participants had included: gastrointestinal, genitourinary, breast, lung, brain, kidney, and hematological. Finally, the articles had inconsistent reporting of race/ethnicity data with only 4 studies reporting this information; of the 4 studies, 91% of participants self-identified as white.

The projects targeted multiple PROs, including physical symptoms and psychosocial issues (ie, stress management, grief, mood, emotional distress, coping, self-efficacy, dignity, joy, affection) domains. Publications dates ranged from 1996 to 2013. The sample sizes ranged from 8 to 322; 11.7%-100% of the study population had advanced cancer, and 20%-100% were living in rural area. The duration of the clinical intervention described was 30-120 minutes. The modes of delivery for the palliative intervention were videoconference/videophone (n = 3), telephone/teleconference (n = 3), and in person (n = 2). The interventions were delivered by nurses, psychiatrists, and social workers. In 5 of these studies, participants received palliative care on an individual basis and 2 studies delivered their intervention through groups. The individual basis studies focused on physical aspects of care and the group studies focused on emotional aspects of care.
 

Patient-reported outcomes

Cancer and its treatments are often associated with physical and emotional sequelae that can have a significant impact on patients and therefore PROs. The interventions reviewed in this article often reported data on the reduction of the physical and/or emotional symptom burden of cancer as well as overall QoL.

Reduction in physical symptoms. Three articles included physical symptoms as an outcome measure. Of those, 2 were pilot or feasibility studies, and 1 was a randomized control trial. Common physical symptoms included: shortness of breath, pain, fatigue, nausea, and appetite change. Across the articles, the Edmonton Symptom Assessment Scale (ESAS), a 10-item inventory of common cancer symptoms, was frequently used to measure of symptom scores in these interventions.^14,15,19 The ESAS is an empirically validated measure that is used in palliative care research and clinical practice. Individuals are asked to rank 10 common symptoms on an ascending scale from 1 to 10 (0, the symptom is absent; 10, worst possible severity).²³