Applebaum, A.J., & Breitbart, W. (2012). Care for the cancer caregiver: A systematic review. Palliative and Supportive Care, 1-22.

A systematic review was used.

• Databases used for the literature search were PubMed, Embase, CINAHL, PsycINFO, and Cochrane Library.
• Key words were cancer caregivers, caregiver burden, and psychosocial interventions.
• Literature addressing the nonprofessional caregivers of people with illness/disease AND the psychosocial impact of the informal caregiver (IC) role AND interventions or coping mechanisms that ease negative impacts of the role was included in the search.
• Noncaregiver participants, nonpatients with cancer, and foreign language articles were excluded from the study.

• A total of 2,199 references were retrieved.
• Two authors performed an initial article title and abstract scan and narrowed the sample to 76 articles.
• Both authors reviewed each of the articles for inclusion and resolved differences of opinion through discussion.

• The review included a final number of 49 studies.   
• Sample range across studies was 8–760.
• Of the studies reviewed, 36 described in-person interventions, 3 described phone-based interventions, and 10 described combined in-person and phone-based intervention strategies.

• Multiple phases of care    
• Pediatrics; elder care; palliative care

Eight major categories of intervention were identified: psychoeducation, problem-solving/skill-building, supportive therapy, family/couples therapy, cognitive-behavioral therapy, interpersonal therapy, complementary and alternative medicine, and existential therapy.

Psychoeducation: Six of nine studies in this category focused on the educational needs of the IC (primarily spouses) at the time of cancer diagnosis or in early-stage disease. Three of nine were targeted to IC/patient dyads with advanced cancer. The IC’s knowledge and ability to provide care was improved, and some studies illustrated positive changes in psychological correlates of caregiver burden as well as level of functional support offered to the patient and marital satisfaction.

Problem-solving/skill-building: Ten studies evaluated the impact of enhancing caregiver ability and confidence to provide care. The majority of studies focused on spouses/partners, one on mothers, and two did not specify the relationship between the IC and patient. Half of the studies provided the intervention to the IC alone, the others to an IC/patient dyad. Eight studies reported significant and positive effects on the psychological correlates of caregiver burden and problem-solving skills.

Supportive therapy: Eight studies evaluated the impact of in-person group therapy (in some studies supplemented by additional phone support), five were targeted to ICs of patients with advanced disease, and three were for ICs of all-stage patients. Five studies utilized groups comprised of ICs alone, and three included IC/patient dyads. Results were generally qualitative, but in those studies where outcomes related to psychological correlates of caregiver burden were measured, one study found improvements by ICs in perceived support and knowledge, and other studies found no significant changes.

Family/couples therapy: Eleven studies focused on interventions to improve communication and psychological functioning of the “couple/family” unit. Of the seven couples-focused studies, all noted improvements by ICs and patients in relationship quality, physical and psychological functioning, communication, and sexual satisfaction. In the four family interventions, significant improvements in psychosocial distress and coping skills were observed. One family-based study, focused on newly diagnosed patients with pediatric cancer, failed to demonstrate significant improvements in anxiety or traumatic stress levels. 

Cognitive-behavioral therapy: Three studies focused on IC interventions using structured, multimodal interventions to impact sleep-wake disturbances, psychological distress, and negative reactions by ICs to patient-reported symptoms. Each study reported significantly positive outcomes postparticipation.

Interpersonal therapy: One study used a phone-based intervention to deliver interpersonal counseling to patients with breast cancer and their spouse caregivers over a six-week period. Significant improvements in depression and anxiety in both parties were reported.

Complementary and alternative medicine interventions: Two studies examined the impact of complementary and alternative medicine therapies. One studied an eight-week, nurse-delivered program of guided imagery, reflexology, and reminiscence therapy to patients and ICs, alternately in person and by phone, but the author collected no psychosocial outcome data. A second study compared massage therapy versus Healing Touch to manage anxiety, depression, fatigue, and subjective caregiver burden on ICs of patients undergoing stem cell transplantation. Significant improvements in anxiety, depression, and physical and emotional fatigue were reported in the subjects who received massage, but neither group noted improved perception of burden.

Existential therapy: One study examined the impact of participation in a theory-based, hope-focused activity on live-in ICs. Qualitative results from the small sample (n = 10) indicated perceived benefits by the participants, such as reframing goals for hope and the value of focusing and sharing their thoughts.

Of the 49 studies reviewed, 65% produced positive improvements in outcomes for ICs and patients, although specific statistical results and effect sizes were not reported. The authors noted that multiple studies did not collect outcome data sufficient to support full comparisons across all studies.

Overall, the body of these studies illustrated that a significant need exists among ICs for information on how to cope with not only their patient’s physical and psychosocial needs but their own as well. The studies that provided concrete skill-building and education (psychoeducational, problem-solving/skill-building, and cognitive-behavioral therapy) met these needs and demonstrated improved outcomes most clearly. Studies with interventions intended to manage psychosocial distress (supportive therapy, family/couples therapy, interpersonal therapy, and existential therapy) generally demonstrated qualitative data indicative of improvements in the psychological correlates of caregiver burden and improved communication, but fewer measured and reported quantitative outcome data allowing larger comparisons of short- or longer-term effectiveness.

The authors of two of the supportive therapy studies noted that during recruitment, ICs with higher baseline levels of psychosocial distress tended to decline participation; therefore, the recruited sample’s mean level of distress at study start was already low to moderate, leaving less opportunity to demonstrate statistically significant change.

A wide variety of interventions to support the educational and psychosocial needs of ICs have been explored, allowing nurses to provide or refer ICs and patients to therapies or structured programs that are best suited to their needs. Some of the interventions are within nursing scope of practice, such as massage, whereas others might require referral to a formal individual or group therapy provider. Structured intervention programs, such as those described in the cognitive-behavioral therapy studies, may be able to be replicated locally.