Tratamientos psicológicos para mejorar la calidad de vida en contextos oncológicos: un meta-análisis

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www.elsevier.es/ijchp

International

Journal

of

Clinical

and

Health

Psychology

THEORETICAL

ARTICLE

Psychological

treatments

to

improve

quality

of

life

in

cancer

contexts:

A

meta-analysis

Alejandro

de

la

Torre-Luque

a_,_∗

_,

_Hilda

_Gambara

b

_,

_Escarlata

_López

c

_,

Juan

Antonio

Cruzado

d

a_Universidad_de_las_Islas_Baleares,_Spain b_Universidad_Autónoma_de_Madrid,_Spain c_ONCOSUR_Granada,_Spain

d_Universidad_Complutense_de_Madrid,_Spain

Received31March2015;accepted20July2015

Availableonline29August2015

KEYWORDS Qualityoflife; Cancer; Psychological interventions; Depression; Meta-analysis

Abstract Thisstudyaimedtoanalyzetheeffectsofpsychologicaltreatmentsonqualityof lifeamongcancerpatientsandsurvivors.Additionally,itwasexploredthemoderatinginfluence ofsomemedical-andtreatment-relatedfeaturesontheseeffects.Scientificstudiespublished between1970and2012wereanalyzed.Seventy-eightstudieswereincludedinameta-analysis. Concernsrelated to samples,interventions,and standardofmethodological evidencewere exploredacrossthestudies.Asignificantoveralleffectsizeofpsychologicalinterventionswas revealed (g=.35). Clinical state anduse ofadjuvant psychologicaltreatment for managing medicalsideeffectsmoderatedthisresult(p<.05).Furthermore,ameta-regressionmodelwas showed significant(R2₌_.30)_so _as_to_explain_the_quality _of_life_change_associated _with psy-chologicalinterventions.Thepsychotherapeuticbenefitsondepressivesymptomatologywere includedasamoderatingfactor.Tosumup,qualityoflifeisimprovedbypsychological inter-ventions,especially whenpatientshavetocopewithmedicaltreatmentorwithadjustment afterthediseaseistreated.Psychologicaltreatmentstendtopromotebetteroutcomeswhen depressive symptomatologyismanaged. Thesefindings supportthat providingpsychological treatmentsshouldbeconsideredascrucialforthepatient’shealthincancercontexts. © 2015Asociación Españolade Psicología Conductual. Publishedby Elsevier España, S.L.U. ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

∗_{Corresponding}_author_at:_Research_Institute_of_Health_Science,_{Scientiﬁc-Technical}_Services_and_University_Research_Institutes,_University

ofBalearicIslands,ValldemossaRoad,km7.5,07122Palma,BalearicIslands,Spain.

E-mailaddress:a.delatorre@uib.es(A.delaTorre-Luque). http://dx.doi.org/10.1016/j.ijchp.2015.07.005

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PALABRASCLAVE Calidaddevida; cáncer; tratamientos psicológicos; depresión; meta-análisis

Tratamientospsicológicosparamejorarlacalidaddevidaencontextosoncológicos: unmeta-análisis

Resumen Esteestudiopretendeconocerelefectodelostratamientospsicológicossobrela calidadde vidadepacientesy supervivientesdecáncer,asícomo la influenciamoderadora devariables médicasy propias deltratamientosobredicho efecto.Paraello, serealizóun meta-análisis queincluyó78 trabajospublicados entre1970y2012. Se analizaronaspectos relacionadosconlamuestra,eltratamientoylacalidadmetodológicadeestosestudios.Como resultado, se encontró un tamaño del efecto significativo de los tratamientos psicológicos sobrela calidad de vida(g=0,35).Dicho efectoestabamoderado porelestadoclínico del paciente y la adyuvancia del tratamiento psicológico con el médico (p<0,05). También se observó quemayores reduccionesde sintomatología depresivadebidasal tratamiento llev-aban a mayores beneficios sobre la calidad de vida según lasmeta-regresiones ejecutadas (R2₌_0,30)._En_conclusión,_los_tratamientos_{psicológicos}_pueden_mejorar_la_calidad_de_vida_de pacientesoncológicos,principalmentecuandodebenafrontartratamientosmédicos,asícomo delossupervivientes.Además,cuandosereducelasintomatologíadepresivalacalidaddevida suelemejorar.Estosresultadosdestacanlainfluenciadecisivadelostratamientospsicológicos paralasaludintegralencontextosoncológicos.

Qualityoflife(QoL)referstoawhole,integratedstateof physical,mentalandsocioemotionalwell-being.This multi-dimensionalconstructiseminently subjectiveandmaybe measured through varying indicators, such as health sta-tusor personal functioning (Ferguson& Cull, 1991; World HealthOrganization,WHO,1948).QoLentailsmorethana mereabsenceofdisease,although itis profoundly associ-atedwithits severity(Amedro etal.,2014; Hogg, Peach, Price, Thompson, & Hinchliffe, 2012; Pagels, Söderkvist, Medin,Hylander,&Heiwe,2012).Forcancerpatients,QoL isacrucialconcernbothwhencancerispresentandwhen the diseasehas been treated (Cheng etal., 2012; Costa-Requena,Rodríguez,&Fernández-Ortega,2013).Oncologic medicaltreatmentsleadtoQoLimprovements, but some-timesawidevarietyofsideeffectscanariseandbringabout signiﬁcanthealth-relatedcomplaints(Decat,deAraujo,& Stiles, 2011; Gogou et al., 2015; Goh, Steele, Jones, & Munro,2013). Likewise, when cancer is treated, patients show higher levels of QoL, but physical and psycholog-ical sequelae often diminish it (Bardwell & Fiorentino, 2012;Duijts etal.,2014;Howard-Anderson, Ganz,Bower, &Stanton,2012).

Facinga canceror itssequelae may leadtosignificant psychologicaldistressandpsychiatricsymptomatology,such assleepdifficulty,excessiveworriesregardingsurvivaland depressivemood.Thesesymptomsareoftenassociatedwith lowerQoLandwell-being(Bornbaumetal.,2012;Oh,Seo, Jeong,&Seo,2012).Awiderangeofpsychological interven-tionsmaybeappliedtoamelioratethepsychologicaldistress andtheadjustmenttobeingacancerpatient,subsequently enhancing QoL (Badr & Krebs, 2013; Preyde & Synnott, 2009).RehseandPukrop(2003)conductedameta-analytic reviewinordertostudytheoveralleffectofpsychological treatmentsthroughout the cancer recovery process.They foundamediumoveralleffectsize(d=.65),though treat-mentlengthshowedasignificantmoderatingeffect.

Morerecently,anothermeta-analysiswasconductedwith similarpurposes.Falleretal.(2013)studied theeffectof psychologicaltreatmentsonemotionaldistressandQoL.In thiscase,psychologicaltreatmentswereobservedtoyield asmalloveralleffectsizeforQoL(d=.26).Moreover,type oftreatmentwasfoundtobeasigniﬁcantmodulating fac-tor regarding this effect, pointing to healthier outcomes whenrelaxationprogramswereapplied,forinstance.These resultsdifferedfromthosefoundinthepriormeta-analysis, probablyduetothedifferencesinsampleselectioncriteria forbothstudies;aswellasthedifferentconceptualizations ofQoLandpsychologicaltreatment.

Becauseofthesediscrepancies,thisstudyaimedto ana-lyzetheoverall effectsizeofpsychologicaltreatmentson QoLincancerpatientsandsurvivors.Ittherebyconsidered following themethodology proposedby RehseandPukrop (2003) for this purpose; however, QoL was studied from a multidimensionalpoint ofview. Furthermore,this study aimed to test whether effect sizes should be considered regarding disease-based features, treatment-related con-siderations,or methodology-related variables.Finally, the presence of signiﬁcant models to explain QoL effects of these treatmentsin relation tomedical-related concerns, andpsychopathologywasstudied.

Methods

Studyselectioncriteria

This meta-analysisis reported according to the Preferred ReportingItemsforSystematic ReviewsandMeta-Analyses forProtocols2015(PRISMA-P2015)statement(Moheretal., 2015) and Botella and Gambara (2006) recommendations. Eligibilitycriteriaforstudiesaredetailedaccordingtothe PICOSframeworkasfollows.

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Participants. Studies with samples composed of adults whosufferfrommalignanttumorsorcancersurvivorswere selected. Studies that included patients suffering from a benigntumorwereruledout.

Interventions.Studiesfocusingonanalyzingtheeffectof apsychologicalinterventiononQoLwereincluded. Psycho-logicalinterventionwasdeﬁnedasnonpharmacologic inter-ventionusingpsychologicalprocedures:psycho-education, coping skills training, counselling, relaxation, alone or in combination,andpsychotherapy(seeHodgesetal.,2011). Theseinterventionsareappliedinordertoimproveeither mental orhealth-related outcomes.Studies withnon psy-chological interventions, such as physiotherapy, physical trainingorotherswereexcluded.

Controls.Studiesthatcomparedtheeffectofa psycho-logical treatment with a control group (either a placebo grouporawait-listgroup)wereselected.

Outcomes. Primary outcome was quality of life (mea-suredbyself-reports),conceptualized froma multidimen-sionalpointofview(WHO,1948);namely,perceivedstate of well-being as a whole, including physical, mental and socioemotional aspects. This outcome can be measured throughdirectindicators (healthstatusandwell-being)as well as more indirect ones (patient’s functioning tests). Secondarily,otherself-reportedoutcomeswereconsidered: anxiety(measuredmainlybyusingBAI,HADS,STAI), depres-sion (BDI, CES-D, HADS as most used instruments), and fatigue(FSI,MFI, asubscaleof FACT-F,asmostcommonly usedinstruments).

Studies.Randomizedcontrolledtrialspublishedbetween 1970 and 2012 in scientiﬁc press (written in English and Spanishlanguages)wereselected.Papersthatdidnotgive enoughdatatoextracttherequiredeffectsizeswereruled out.

Studyselectionprocedure

Studies were selected by reviewing the meta-analysis of Rehse and Pukrop (to select articles between 1970-1999) and four issue-related ones (Badr & Krebs, 2013; Faller et al., 2013; Osborn, Demoncada, & Feuerstein, 2006; Preyde & Synnott, 2009). Additionally, it was conducted

some database searches (March, 2013). As key terms,

‘neoplasm(s)’, ‘psychotherapy’,and ‘qualityof life’ were considered; aswas the referencestudy (Rehse & Pukrop, 2003).SearchqueriesareattachedinTable1.

Each study was selected when two reviewers

inde-pendently considered it satisﬁed the selection criteria. Thus, papers were screened through an initial review of title,abstract,andkeywords.Afterwards,thepre-selected manuscriptswerereadfullytoendorsetheselection crite-riaweresatisﬁed.Meanwhile,adescendentsearchprocess wasperformed:allthearticlescitedinselectedmanuscripts werereviewed.

Outcomedomainsandcodedvariables

Relevantdataofthestudieswereextractedandcodedusing a database developed for these purposes by a reviewer. Furthermore,theotheronetestedcodingtoolsbyreading andcategorizing arandomselection of thestudy sample.

Table1 Searchstrategyadaptationsforeachdatabase.

Database Searchstrategy

CINAHL Boolean:

((neoplasm)or(cancer)) AND(psychotherapy)AND (‘‘qualityoflife’’) CochraneDatabase NEOPLASMAND

PSYCHOTHERAPYAND ‘‘QUALITYOFLIFE’’[1999 -2012]

Filter:RCT

OvidSPNursingDatabase ((neoplasm)or(cancer)) AND(psychotherapy)AND (‘‘qualityoflife’’) Proquest:

MEDLINE®_(1999-2012) ProQuestHealth& MedicalComplete ProQuestLibraryScience (1970-2012) ProQuestPsychology JournalsPsycARTICLES (1894-2012) PsycCRITIQUES (1995-2012) PsycINFO(1806-2012) PsycTESTS all((neoplasm)or(cancer)) ANDall(psychotherapy)AND all(‘‘qualityoflife’’)

PubMed (‘‘Neoplasms’’[Mesh])AND (‘‘Psychotherapy’’[Mesh]) AND(‘‘Qualityof Life’’[Mesh]) Filter:RCT

Psicodoc ((neoplas*)o(cancer))y (psicoterapia)y(calidadde vida)

Scopus (TITLE-ABS-KEY(neoplasm

ORcancer)AND TITLE-ABS-KEY(psychotherap*)AND TITLE-ABS-KEY(‘‘qualityof life’’))ANDPUBYEAR>1998 AND(LIMIT-TO(LANGUAGE, ‘‘English’’)OR LIMIT-TO(LANGUAGE, ‘‘Spanish’’))AND (LIMIT-TO(DOCTYPE,‘‘ar’’)) AND(LIMIT-TO(SRCTYPE, ‘‘j’’))

WebofScience Topic=((neoplasmor cancer))AND

Topic=(psychotherapy)AND Topic=(‘‘qualityoflife’’) Timespan=1999-01-01 -2012-12-20.

Databases=SCI-EXPANDED, SSCI,A&HCI.

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Thisselection encompassed 25%of thetotal sample.As a result,80%oftherelevantdatawereequallycodedbythe tworeviewers,␹2 ₍₁₎₌_63.00, _p_<_.01._{Disagreements}_were resolvedbydiscussion.

As a dependent variable,theeffect size,extracted by comparing QoL scores between experimental and control groupafterpsychologicaltreatment wasapplied,was cal-culated.Datawerecollectedbyvalidatedinstrumentsthat assessed QoL from concepts such as integrated sense of well-being,aswellasintegratedperceptionofhealthand functioning.Mostusedinstruments arestatedin Ferguson andCull(1991).

Eight categoricalfactorswereconsidered inthis meta-analysis (see Table 2). Additionally, several quantitative moderating factors were studied: the mean age of par-ticipants, gender-related proportions within samples and clinicalsymptomatology(levelsofdepression,anxiety,and cancer-relatedfatigue).

Dataanalyses

Asingleeffectsize wascalculated foreach study,forthe dependentvariableaswell asfor thequantitativeclinical factors.Thesecalculationswerebasedonthestandardized difference of group means after psychological treatment byusingtheHedges’gstatistic(Botella&Gambara,2002; Hedges&Olkin,1985).Theunbiased estimatorofgbased ongammafunctionwasthereforeapplied(seeEquation1). Effectsizeswereinterpretedaccordingtotheguidelinesby

Cohen(1988).

g=d•[c(m)] (1)

Differentruleswereusedinordertoavoiddependency between measures. Firstly, if there was more than one experimentalgroup, thegroup whosepsychological treat-mentwasmorecommonwasconsidered.Iftherewasmore than oneinstrument tomeasure QoL in a study,only the instrumentshowingthehighestreliabilitywaschosen. Addi-tionally, the overall effect size was calculated. This was weighted by the inverse of variance of the single effect sizes(seeEquation2),whichisobtainedthroughthesingle intra-studyvariabilityandanestimateofthebetween-study variance(Botella&Gambara,2002).

¯g= k i=1wi∗gi k i=1wi (2) Afterwards,homogeneitybetweenstudieswastestedfor byusingtheQt statisticandtheI2index(Hedges&Olkin, 1985;Higgins&Thompson,2002).Ifthenullhypothesiswas rejectedforthistest,thepresenceofexplanatory models hadtobestudiedinordertoﬁndfactorsrelatedtothese systematicvariations.

Explanatorymodelﬁttingwasthereforeconsidered.We ﬁrstlyanalyzedthemagnitudeofmoderatingeffectsderived fromcoded categorical factors by means of analogues of analysisof variance (Hedges & Pigott, 2004).Forest plots wereattachedtocomplementtheseanalysesvisually.

Allofthesecalculationswereconductedassuming ran-domeffectsmodels(Hedges&Pigott,2004;Sánchez-Meca, Marín,&Huedo,2006).

Table 2 Categorical variables considered in this meta-analysis.

Variables Codingcategories Typeofcancer Breastcancer

Lungcancer Prostatecancer Others

Patient’sclinicalstate Activetreatment Terminalillness Remission(survivors)

Samplescomposedofpatients withdifferentstates

Adjuvantpsychological treatment

Noadjuvancy

Psychologicalinterventionsto palliatesideeffectsofmedical treatments Typeofpsychological intervention* Psychoeducational interventions Supportgroups

Copingskillstrainingprograms

Psychotherapy

Formatofintervention Individual

Couple

Grouptreatment

Mixedformats

Durationoftreatment Shortinterventions(<15

sessions) Longinterventions(≥15 sessions) Instrumenttomeasure QoL† QoLasawhole Health-relatedQoL Cancer-speciﬁcQoL Treatment-speciﬁcQoL Methodologicalqualityof studies‡ Strongquality Moderatequality Lowquality Note.

* _Classiﬁed _according _to _Cunningham ₍₁₉₉₅₎_, _although

spir-itual/existential therapies were considered a branch of psychotherapies.

† _According_to_Murphy,_Ridner,_Wells,_and_Dietrich₍₂₀₀₇₎_._The fourth categorywas includedbecausethereare many instru-mentsadaptedforeachtypeofdeﬁniteoncologicintervention insteadofsymptom-speciﬁcQoL(inthismeta-analysisQoLwas consideredasamultidimensionalconstruct).

‡ _Assessed_using_the_Quality_Assessment_Tool_for_Quantitative Studies(Thomas,Ciliska,Dobbins,&Micucci,2004).

Meanwhile, quantitative model ﬁtting was also tested by means of multiple meta-regression. The factors con-sidered wereincorporated intotwodifferentmodels:one comprising sociodemographic and medical related factors (gender, sample age, clinical state, use of adjuvant psy-chological interventions for managing the side effects of medical treatment, and fatigue); another that involved emotionalsymptomatology(anxietyanddepression).Model estimations were extracted by using maximum likelihood basedmethods(Botella&Gambara,2002;Hedges&Pigott, 2004).

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Descending search approach

Search results combined (n=1,330)

Ascending search approach (n=17)

Excluded for not satisfying

Excluded for not satisfying - Sample criteria (n=92) - Intervention criteria (n=99) - Controls criteria (n=9) - Outcomes criteria (n=225) - Study criteria (n=639) - Sample criteria (n=4) - Intervention criteria (n=6) - Controls criteria (n=10) - Outcomes criteria (n=92) - Study criteria (n=76) Screening review Included (n=266) Included (n=78) Manuscript review - Rehse and pukrop meta-analysis (n=37)

- Database (n=1,110) and meta-analyses (n=166)

Figure1 Flowdiagramofstudyselection.

Note.Screeningreviewwasbasedontitlearticle,abstract,andkeywords.

Finally, publicationbiaswasassessedbyusing contour-enhancedfunnelplotsandtheEgger’sregressiontest (see

Mavridis&Salanti,2014).

SPSS v.19 (scriptby Lipsey& Wilson, 2001) andR x64 3.0.1(METAFOR1.9-1package)wereusedtoconductthese analyses.

Results

Figure1depictsthestepsfollowedtoobtainthestudy sam-ple.Aninitialsampleof1330originalpaperswasreviewed. Uponthe study selection stage wasover, 78 studies were deﬁnitely included in thismeta-analysis*_._Study _reviewers

agreedonsampleselection.Allofthesestudieswere writ-tenin theEnglishlanguage.The bulkof studiesshowed a mediumlevelofmethodologicalquality(60.20%ofsample) incontrastwithstrongandweaklevels(24.40%and15.40%, respectively).

Atotalof7,342individualscomposedthestudies.Mean ageofparticipantswas54.82yearsold(SD=7.36).Regarding the type of oncologic disease, almost half of the studies were focused on samples with breast cancer (46.20% of studies).Moreover,thestudiesweremainlyfocusedon sam-plesunderoncologicmedicaltreatment(82.90%ofstudies, respectively).

Regardingtheuseofadjuvantpsychologicaltreatment, 14.10%ofstudiestestedtheeffectsofpsychological treat-ment onadverse symptomatologyderived froma medical

∗_List _of _studies _and _{codiﬁcation} _manual _are _available _upon

requestfromthecorrespondingauthor.

treatment.Regardingthetypeofpsychologicaltreatment,

the most common type was psychotherapy (46.80% of

studies); while the most common format was individual treatment(54.10%ofstudies)andshort-termones(76.30% ofstudies).

ConsideringhowQoLwasassessed,morethanthehalfof thestudies usedinstruments that evaluatehealth-related QoL;fewerstudiesusedinstrumentsthatmeasuregeneric QoL cancer-speciﬁc or treatment-speciﬁc QoL (24.40%, 19.20%and3.80%ofstudies,respectively).

InstrumentsusedtomeasureQoLshowedadequate lev-els of reliability, as Cronbach’s alpha statistic conﬁrmed (Mdn=.89, range=[.69, .95]), as well as those used to measuredepression(Mdn=.82, range=[.70,.91]),anxiety (Mdn=.85, range=[.74, .93]), and cancer-related fatigue (Mdn=.93,range=[.82,.97]).

Distributionofeffectsizes

Singleeffectsizesinrelationtotheeffectofpsychological treatmentonQoLrangedbetween-.41and2.37andstudy variances between .01 and .59. Regarding overall effect size,itwasfoundthatg=.35,CI95=(.25,.45),withcontrast

statisticZc=7.51;p<.01.Thebetween-studyvariabilitywas

v=.10 amongthe 78 studies analyzed. These results sug-gestthepresenceofasmall-to-mediumoveralleffectsize ofpsychologicaltreatmentsonQoL.

Afterwards,thehomogeneitytestsrevealedasigniﬁcant heterogeneitybetweenstudies,Qt(77)=243.80;p<.01;and

I2₌_68.42%._These_ﬁndings_suggest_that_differences_between

singleeffectsizes weretoolargetoconsiderbeingdueto randomeffects.

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Patients under medical treatment Non-adjuvant treatment Adjuvant psychological treatment Overall ES Survivors Overall ES .10 .30 .50 g CI95 g CI95 .24 [.16, .32] .46 [.25, .66] .35 [.25, .35] .29 [.19, .39] .74 [.49, .99] .35 [.25, .45] ES quality of life

A

B

.70 .00 .40 .80 ES quality of life

Figure2 Overalleffectsizesinrelationtosigniﬁcantcategoricalmodels.

Note.Thisﬁgureincludesoveralleffectsizesinfunctionoftwocategoricalfactors.TheGraphAdepictsoveralleffectsizesregarding

patient’sclinicalstage.Likewise,overalleffectsizesinfunctionofwhetherthepsychologicalinterventionisappliedforreducing

theeffectsofongoingmedicaloncologictreatments(adjuvanttreatment)ornot,arepresentedintheGraphB.

Overalleffectsizesforallcategorieswithconﬁdenceinterval(betweensquarebrackets)areincluded.ES=Effectsize.

Categoricalmodelﬁtting

Categorical modelsweretested separatelytoanalyzethe influenceof each moderatingfactor onthe effectof psy-chologicaltreatments.As a result,two significant models showed differences between categories. The first model wasrelatedtopatient’s clinicalstate,withQb (2)=10.37;

p<.01.Although,wereconsideredtheseanalyses inorder toclarify the trueeffectof thismoderator. Thus,we dis-cardedthestudieswithmixedsamplesandthestudieswith terminalpatientsduetothesmallsampleofstudies.Hence, clinicalstatemodelwasrecalculatedusingtwocategories: survivors(k=9),andcancer patientsundermedical treat-ment(k=58).Asaresult,signiﬁcantdifferenceswereagain found between categories, Qb (1)=3.89; p<.05. Figure 2

showstheoveralleffectsizesofthesecategories.Thus,a small-to-mediumoverall effectsizewasobservedin stud-ieswhichanalyzedtheeffectsofpsychologicaltreatments onsurvivors.Studieswithpeopleundermedicaltreatment showedalowereffectsize.

Furthermore,signiﬁcantdifferencesbetweencategories were found regarding the use of adjuvant psychological treatment(seeFigure2),withQb(1)=10.78;p<.01.Thus,

whenpsychologicaltreatmentwasappliedwhileamedical treatmentwasongoing (k=11),inordertoamelioratethe sideeffects,theoverallsizeeffectwasgreaterthanwhen treatmentwasnotappliedforthesepurposes(k=67).

Quantitativemodelﬁtting

Overall effect size was calculated for the quantitative moderating factors, observing small overall effect sizes for fatigue(g=.21, CI95=[.07,.34]; Zc=2.99, p<.01)and

depression(g=.38,CI95=[.21,.54];Zc=4.45,p<.01);and

amediumoveralleffectsizeforanxiety(g=.54,CI95=[.33,

.76];Zc=4.88,p<.01).

Afterwards,themeta-regressivemodelswereestimated independently. The model composed of sociodemographic andmedicalfactorswastested first,buta non-significant effect was found for that (p>.05). The model based on emotionalfactorswasthentested.Thus,significantfitting was observed for this model, with QR (2)=15.10; p<.01.

Thismodelwascalculatedfromasampleof32studiesand a considerable explainedvariance of criterionwasfound,

R2₌_.30._However,_factorial_loading_for_depression,_and_not

anxiety,wasrevealed assigniﬁcantlydifferent fromzero; withB=.73,CI95=(.35,1.11);andZc=3.78;p<.01.

These results highlight the importance of depressive symptomatology ameliorations in order to delimit the yieldedeffectofpsychologicaltreatmentsonQoL.

Publicationbias

Acontour-enhancedfunnelplotwasconductedandexplored first (see Figure3). As a result,it waspossible to visual-ize that a publication bias may affect the results of this meta-analysis, due to the presence of some asymmetry withinthegraph.Egger’sregressiontestsupportedthis find-ing,withZ=5.75,p<.05.Thisresultmeansthatsignificant asymmetry was found, and the results derived from this meta-analysisshouldbeconsideredcautiously.

Discussion

Qualityoflifeandrelatedconstructsbecomemorerelevant overtime(e.g.,seeMiretetal.,2015).Infact,QoLisone ofthemostimportantconcernsforcancerpatientsand sur-vivors.Thisstateshouldbeconsideredasmultidimensional inordertopromoteintegrativepatient-centeredcare.Itis therefore recommendedthat multidisciplinaryapproaches are taking withinoncologic contexts. Psychological treat-mentsshouldtakepartinthiscontext.Theseenableabetter

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–2.00 .768 .576 .384 .192 .000 –1.00 .00 ES quality of life Standard error 1.00 2.00 3.00

Figure3 Contour-enhancedfunnelplotforpublicationbias detection.

Note.Statisticalnonsigniﬁcanceforasymmetryisdisplayedat

99% (white area),95% (grey area) and90% (dark grey area)

conﬁdenceinterval.

therapeuticmanagementofemotionalsymptomatologyand thepromotionofmoreadaptivecopingskillsinordertoﬁght againstcancer.Consequently,psychologicaltreatmentslead toimprovingtheglobaladjustmenttodailyenvironmentand increasingthesense ofwell-being (Andersen etal.,2010; Cordella&Poiani,2014).

Thisstudyaimedtoshedlightonthetrueeffectsof psy-chologicaltreatments in cancer contexts. Concretely, the effectofthesetreatmentsontheQoL ofpeoplewho suf-ferfromcancerorsurvivors.Moreover,westudiedwhether differentmoderatorsmightinﬂuencethisoutcome.

Accordingtoourresults,astatisticallysignificant over-all effect size of psychological treatments was observed regarding the integrated sense of QoL of cancer patients andsurvivors.Concretely,asmall-to-mediumoveralleffect sizewashighlighted.Thisresultenablesustosuggestthat psychologicaltreatmentsyieldsignificantbenefitsonQoLin cancerpatients.Thiseffectsizeissmallerthantheresults foundbyRehseandPukrop(2003);althoughittendstoagree morewiththe ones shown inthe recentmeta-analysisby

Falleretal.(2013).Theseauthorsshowedanevensmaller overall effectsizethan thecurrent study.It is likelythat divergences between the results derived from these two meta-analyses and the current one could be related to protocol keepingbetweenthe studies.Firstly, itis impor-tanttohighlightthatthecurrentstudyconsidersQoLfrom a multidimensional perspective. Moreover, psychological treatmentswereconceptualizedaccordingtoHodgesetal. (2011),andcodedfollowingtheclassiﬁcationofCunningham (1995).Thisclassiﬁcationisfocusedonpatients’needsand levels of involvement in their recovery process along the disease trajectory(Hopkins & Mumber, 2009).Conversely,

Falleretal.(2013)assumedsampleselectioncriteriabased only partially on thesereferenced frameworks (i.e., only face-to-facetreatmentswereconsideredwithinthestudy, ruling out treatments that incorporated other forms of

delivery); indeed, they followed another classiﬁcation of psychologicaltreatments.

Ontheotherhand,thecurrentstudyandthereference ones agree upon the fact that psychological treatments cannot show a unified effect size. In our meta-analysis, twoof the studied variables were revealed as significant moderating factors in this regard. The first one was the patient’s clinical state. Thus, it was found that psycho-logicaltreatmentspromotegreater QoLfor survivors.The benefitsofpsychologicaltreatmentsseemedtofadeaway in patients under active treatment. Medical treatments toward the healing may be rather more crucial through-out cancer healing process. Nevertheless, psychological treatments become more effective when patients had to copewiththesideeffectsof ongoingmedicaltreatments, such as surgery, chemotherapy or radiotherapy (Cheung, Molassiotis, & Chang, 2003; Svensk et al., 2009). Hence, theeffectof reducingsomatic anxiety,sleepproblems or other symptomatologywhich are a consequence of medi-caltreatmentsisnoteworthy.Furthermore,whencanceris treated,psychologicaltreatments canplay amore impor-tantrole,asthe results of thismeta-analysishighlight. A personwho recovers froma cancer has toadapt todaily lifeindifferentconditionsthanbefore.Thus,survivorstend toshow some physical and psychological sequelae, situa-tionsofdisabilityandhandicap,andimportantcontextual changes(jobloss, newfamiliar roles,etc.). These events takentogetherimpactwell-beingandQoLandcanbecoped withmoreeffectivelybytheaidofpsychologicaltreatments (Mannetal.,2012;Osbornetal.,2006).

Italsoisnoteworthythatthisstudyfoundnosignificant effects of other moderators. Thus, neitherother medical factorsnorintervention-related aspectsstudied showeda significantinfluenceonthepsychological-treatmenteffects on QoL. This fact is not aligned with findings from the aforementionedworks(Falleretal.,2013;Rehse&Pukrop, 2003), probably due to different conceptualizations and theincorporationofmore recentstudies.Regarding other modulatingfactors,theroleofdepressivesymptomatology ameliorations should be highlighted to address the bene-fitsofpsychologicaltreatmentswithinoncologiccontexts. Inthissense,the psychologicaltreatmentsthat promoted greater reductions in depressive symptomatology yielded greater benefitson QoL. This statementwasendorsed by theresultsderived fromthemeta-regressive analyses.No otherstatisticallysignificantloadingswerefoundneitherfor sociodemographicfeaturesofpatients,medicalfactorsnor anxietyameliorations.

These results highlight that psychological treatments whichamelioratedepressivesymptomatologycanpromote greaterlevelsofQoLinoncologiccontexts.Depression,and itsrelated symptomatology,is considered a risk factor of cancerincidenceandprogression(Boydetal.,2012;Currier & Nemeroff, 2014). Hypothalamus-pituitary-adrenal (HPA) dysregulationandimmunologicalalterationsareimpliedin thisstatus (Lutgendorf & Sood, 2011; Sotelo, Musselman, & Nemeroff,2014; Thornton,Andersen, & Blakely,2010). Depressive symptomatology therefore impacts defensive immune-mediated responses against cancer. Additionally, tumorexpansionisencouragedbyHPA-mediatedresponses thatarecharacteristicofdepressivesymptomatology. Con-sequently,decrements ofdepressivesymptomatologymay

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leadtocancer-relatedadverse effectsbeingbufferedand QoL becoming higher (Barrera & Spiegel, 2014; Howren, Christensen,Karnell,&Funk,2010).

To sum up, this study highlights a signiﬁcant small-to-mediumoveralleffectsizeofpsychological treatmentson QoL, within cancer contexts. This effect should be con-sidered when taking into account medical variables (the patient’s clinical state and the application of psychologi-caltreatmentsto palliateside effects of amedicalone). Moreover, it recommends that components for reducing depressivesymptomatology areincorporated into psycho-logicaltreatment.

Asstrengths,thismeta-analysisincludesawideamount of studies, encompassing both more classical and more recentones, keepingwell-validated protocols whichwere usedinthereferencestudy.Indeed,robustdefinitionswere consideredandamultidimensionalperspectivetoviewQoL wasfollowed. These strengthsenableus toprovide some evidenceinordertocomplement priorprominentfindings (Falleretal.,2013;Rehse&Pukrop,2003).Thisstudy there-foresuggeststhatpsychologicaltreatmentsyieldsignificant improvementsonQoL, providedthatthemedicalstate of patientistakenintoaccount.

As limitations, this meta-analysis could have incorpo-ratedothertypesofstudies(i.e.,pre-experimentalstudies) eventhoughthesestudieshadalowermethodological qual-ity.However,inthiscase,variablesrelatedtotheabsence ofexperimentalcontrolscouldhavebeenaddedandcould havestainedtheactualresultsofthismeta-analysis.Onthe otherhand,othermodulatingfactorscouldhavebeen con-sidered(i.e.,experienceofimplementers,personalitytraits ofpatients,etc.).Futureresearchshouldincorporatethese inordertoclarify thetrue effects ofpsychological treat-ments.Finally, thepresenceofpublicationbiasispointed outin thisstudyaswellasinotherrelatedmeta-analyses (Falleretal.,2013;Osbornetal.,2006);thisinvolvesthat theseresultsshouldbeconsideredcautiously.

This study intends tocontribute toward understanding thediseaseburdenofcancerandtheimportanceof psycho-logicalinterventions,aswellassuggestingpopulationsmost likelyto help. Psychological treatments play a signiﬁcant roleinintegratedcarewithincancercontexts.These treat-mentshelpimprovementalhealthandpersonalwell-being throughoutthetrajectoryofthepotentiallylife-threatening cancer experience. Well-being and QoL remain as crucial factorstopromotesuccessfuladjustmenttodaily environ-mentsafterovercomingthisdisease.

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