Goedendorp, M. M., Gielissen, M. F., Verhagen,  C. A., & Bleijenberg, G. (2009). Psychosocial interventions for reducing fatigue
during cancer treatment in adults. Cochrane Database of Systematic Reviews, 1, CD006953.

To evaluate if psychosocial interventions are effective in reducing fatigue and to consider which interventions are the most effective.

Databases searched were Cochrane Central Register, PUBMED, MEDLINE, EMBASE, CINAHL, and PsycINFO to September 2008. Hand searching of reference lists was also performed.

Extensive keywords and specific search terms per database were provided.

Studies were included in the review if 

• They reported adult participants receiving active curative or palliative treatment
• The intervention involved a systematic intervention consisting of a process between the patient and the provider
• The intervention included at least two contacts between the patient and provider and, during the intervention, the provider gave the patient some type of individual feedback
• Fatigue was at least one of the outcome measures
• They were randomized, controlled trials.

Patients were excluded if they were breast cancer survivors receiving only hormonal therapy and were not considered in active treatment.

In total, 85 references were retrieved. The Jadad scale criteria were applied for quality rating, as well as additional criteria identified by vanTulder (1997).

• The final number of studies included was 27; seven studies (n = 969) were aimed specifically at fatigue.
• The sample range across the studies was 60 to 396 patients.
• All patients were receiving various active treatment types.
• Various diagnoses were involved, but the majority of studies were performed on women with breast cancer.

• Patients were undergoing multiple phases of care.
• The study has clinical applicability for palliative care.

In most studies, it was unclear at what stage of cancer the intervention ended. In most studies, the interventions were given by nurses. Formats varied and included intervention in groups; combination of face-to-face and telephonic support; and provision of additional written, videotape, or audiotape information. The number and duration of sessions varied across studies. In four studies, participants received an intervention of the same number and duration for the attention control. The number, type, and timing of outcome assessments also varied. Most studies used one instrument to measure fatigue, with the Profile of Mood States (POMS) used most often. Only five studies used a measure specifically defined to measure fatigue. Only three studies scored at least a three on the Jadad quality scale, and only one study had a good evaluation of quality scoring related to internal validity. Most had a moderate quality. Seven studies reported a significant effect on fatigue, with effect sizes ranging from 0.17 to 1.07 (p ≤ 0.05). In two of these, there was an immediate effect, but the results were not maintained at follow-up. Twenty studies were regarded as not effective. Interventions specifically aimed at fatigue, rather than multiple additional symptoms, tended to be more effective for fatigue.

Findings showed that there was no solid evidence that interventions not specifically focused on fatigue were effective in reducing fatigue. Overall, there was limited support and conflicting results for psychosocial interventions on fatigue during cancer treatment. Studies that showed an effect included education about fatigue and teaching in self-care or coping strategies and taught activity management, balancing activity, and rest.

• Only studies involving patients during active treatment were included, so the findings may not apply to other patient groups.
• There were indications that prevalence and course of fatigue may depend on the type of treatment received.
• Heterogeneity among studies in these factors limited the ability to draw firm conclusions regarding the effectiveness of various interventions.

Psychoeducational interventions, including education about fatigue, helping patients in self-care and coping, and teaching patients to balance activity and rest, may be helpful in alleviating fatigue among patients receiving cancer treatment. The degree and timing of fatigue can vary according to treatment type and the cancer trajectory. The most effective interventions based on treatment and phase of care were not clear, and further research in this area is warranted.