Cobeanu, O., & David, D. (2018). Alleviation of side effects and distress in breast cancer patients by cognitive-behavioral interventions: A systematic review and meta-analysis. Journal of Clinical Psychology in Medical Settings, 25, 335–355.

• STUDY PURPOSE: Ascertain the effect of cognitive-behavioral interventions (CBI) in patients with breast cancer during active treatment for breast cancer; determine effect sizes on side effects of treatment, distress, and quality of life; determine moderators of effect size.
• TYPE OF STUDY: Meta-analysis and systematic review

• DATABASES USED: PsycINFO and MEDLINE
• YEARS INCLUDED: 1996-2012
• INCLUSION CRITERIA: Randomized control trial to assess the efficacy of CBI in side effect management of breast cancer during treatment. Interventions studied were started upon treatment initiation or before completion of treatment. The study must have included a control group, was in English, and publications were from a peer-reviewed journal. Paper must have sufficient data to compute an effect size
• EXCLUSION CRITERIA: Studies that focused on alleviation of surgical side effects; studies that investigated CBI use in physical symptoms not associated with treatment side effects.

• TOTAL REFERENCES RETRIEVED: 786
• EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Criteria applied for inclusion in meta-analysis were listed in publication. There was no method to assess the risk of bias in individual studies and no report of the quality of studies included.

• FINAL NUMBER STUDIES INCLUDED: 19 
• TOTAL PATIENTS INCLUDED IN REVIEW: 2,220
• SAMPLE RANGE ACROSS STUDIES: 34-303
• KEY SAMPLE CHARACTERISTICS: Patients with breast cancer receiving neo-adjuvant or adjuvant treatment.

PHASE OF CARE: Active anti-tumor treatment

Overall, results demonstrated a modest but statistically significant effect on side effect improvement (p = 0.005) with CBI. More specifically, CBI was associated with statistically significant improvements in nausea and vomiting (p < 0.001), overall distress (anxiety and depression, mood, stress, hostility) (p < 0.001), anxiety (p = 0.001), and quality of life (p < 0.001). The review results found non-significant effects on fatigue (p = 0.63), sleep disturbance (p = 0.314), pain (p = 0.854), and depression (p = 0.063). The authors hypothesized that this lack of significance could be due to low power of analysis across the studies on fatigue, sleep, and pain, as well as lack of tailored interventions specific to those symptoms. Lack of significance for CBI on depression could be due to failure to pre-screen participants for depression prior to beginning the intervention.

CBI is effective in reduction of many physical and psychological distress symptoms, including nausea and vomiting, anxiety, and quality of life. Additional research are studies with larger sample sizes are needed to further validate findings. In addition, further research is needed to examine which CBI protocols are most effective for specific symptoms, as well as greater uniformity in the reporting of CBI interventions.

• Limited number of studies included
• No quality evaluation
• High heterogeneity
• Inconsistency in reporting of intervention descriptors such as length of treatment and types of professionals administering the intervention

CBI has efficacy in improving some physical and psychological symptoms and quality of life in breast cancer patients undergoing active therapy. It is important for nursing to assess and advocate for patients who may benefit from CBI and facilitate access to such interventions as part of the overall treatment plan.