Orientation and Information Provision

To assess effects of interventions that orient patients and carers to a cancer care facility and to the services provided

• Databases searched were Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and PsycINFO. Investigators also searched reference lists and abstracts from relevant proceedings. Specific journals were searched separately.
• Authors provide an extensive listing of search terms and specific search language for each database. In addition to all relevant terms for cancer, key terms included patient education, patient information, mass communications, audio, video, cassette, tape, dvd, compact disc, media, multi media, internet, website, pamphlet, booklet, and phone or print material.
• Studies were included in the review if they were randomized controlled trials (RCTs) and quasi-RCTs that compared the effect that orientation achieved in an intervention group with the effect achieved in a control group or compared one orientation intervention with another orientation intervention.

Initial searching identified 14,319 records. Investigators assessed 21 full-text articles for eligibility, and the systemaic review included a sample of four. Two studies were included in meta-analysis. Study quality was assessed using guidelines in the Cochrane Handbook for Systematic Reviews of Interventions.

• The final sample of four studies involved 631 patients.
• Sample sizes were 31–304 and included new patients, over 18 years of age, with cancer.
• All studies allowed family and carers to receive the intervention along with the patient.
• Various diagnoses were represented.

• Studies were generally of low to very low overall quality.
• Components of the oreitnation programs were information about the healthcare team, a clinic tour, information about the facility (parking, hours of operation, etc.), description of clinical procedures, information about supportive services available, treatment-related information, and question-and-answer sessions.
• Formats used were written materials in all studies and videotape in one study. Interventions were delivered via mail or face-to-face. Timing of orientation varied. Intervention intensity could only be measured by length of time taken for reading or watching a video or duration of face-to-face interactions.

Effects of Interventions

• Knowledge and understanding: Two studies reported better knowledge and understanding with the intervention or risks, benefits, and side effects of treatment. Pooled analysis of these results gave a mean difference (MD) of –0.18, 95% CI –1.02 through 0.66.
• State anxiety: Two trials measured effect on state anxiety. Pooled analysis showed MD of –9.77, 95% CI –24.96 through 5.41. In one of these trials, there was a significant difference in trait anxiety between study groups at baseline.
• General anxiety: One trial measured general anxiety by using the Brief Symptom Inventory and found no differences between groups.
• Mood disturbance: Two trials evaluated general distress. Analysis showed significant difference in favor of the intervention group (MD = –8.96, 95% CI –11.79 through –6.13).
• Symptoms of depression: Three studies reported positive benefits of the intervention on symptoms of depression. Postintervention meta-analysis showed no difference in depression scores (MD = –0.4, 95% CI –2.95 through –2.15).

This review shows that orientation programs may reduce distress in patients with cancer at the beginning of their involvement with a cancer care facility, but the quality of the evidence is low. Orientation programs may have some effect on general distress and symptoms of depression; however, findings do not show significant effects on anxiety.

These findings are limited by the small number of trials included, low quality of studies, and high heterogeneity found related to some outcomes.

Orientation of the patient, the patient's family, and those who care for the patient may help to reduce a patient's symptoms of depression and level of distress; however, this study does not reveal strong support for these outcomes. The most effective format and timing of orientation approaches are unclear.

To investigate the effects of cognitive behavioral therapy (CBT) and patient education (PE) on anxiety in adult cancer survivors

Databases searched were MEDLINE, PsycINFO, and the Cochrane Database (1993–2004).

Search keywords were cancer, anxiety, depression, quality of life (QOL), fatigue, stress, pain, physical function, social, self-management, evidence-based, interventions, and random/randomized.

Studies were included in the review if they

• Reported on adult patients with cancer (all types and stages)
• Had a control group, randomization, and measurable outcomes of interest (anxiety, depression, fatigue, QOL, physical function, and pain)
• Had at least one follow-up assessment beyond post-treatment, which allowed for examination of duration of effects.

Studies were excluded if they were not randomized or controlled, had a score of less than four on checklist, did not report follow-up data, or did not report data on targeted outcomes.

Dissertations were excluded.

• A total of 592 studies were evaluated, with only 19 studies meeting criteria. Comprehensive meta-analysis was used to determine effect size for each outcome.
• Quality was assessed by a modified version of Jadad’s six-item checklist (randomization, double blinding, descriptions of withdrawals and dropouts, statistical analyses, inclusion and exclusion criteria, and adverse effects).
• Longitudinal study: Times of measurement varied from one week to 14 months. Median follow-up was defined as short-term (less than eight months) and long-term (more than eight months).
• Four studies reviewed used CBT for anxiety.
  • CBT sessions varied from four weekly one-hour sessions to 55 weekly two-hour sessions.
  • CBT included stress management and problem-solving approaches.
• One study reviewed used PE for anxiety.
  • PE sessions varied from one 20-minute session to six weekly one-hour sessions.
  • PE included information about illness, symptom management, and discussion of treatment options using booklets, videos, and other educational materials.

• The review reported on 1,492 adult cancer survivors.
• All types and stages of cancer were represented.
• Survivor age range was 18–84 years.
• 790 survivors were assigned to interventions, and 702 were assigned to control (medical management only).

• CBT interventions on anxiety (four studies):
  • Large effect was noted for individual and group CBT (g = 1.99, p < 0.01; 95% CI 0.69–3.31).
  • Of these four studies, a sensitivity analysis revealed a large effect size for individual treatment (g = 2.41, p < 0.01; 95% CI 1.2–3.55) and no effect for group interventions (d = 0.03, p+0.82; 95% CI -0.20–0.25).
  • Forest plots representing the effect sizes of CBT on anxiety favor the intervention.
• The single trial using PE to decrease anxiety resulted in no short-term effect on anxiety and did not include long-term follow-up on anxiety (d= -0.02, p = 0.89; 95% CI -0.36–0.31).

• Analysis did not consider patient adherence to pharmacologic interventions, which is known to be modest in medical patients.
• No cost-benefit implications were noted.

CBT is effective for short-term management (less than 8 months) of anxiety. Individually based interventions were more effective than those delivered in a group format. Various CBT approaches provided in an individual format can assist cancer survivors in reducing the emotional distress of anxiety.

The intervention was a 12-minute cancer orientation program video and an orientation booklet. The video provided an overview of the cancer center, a welcome statement, an introduction to the clinic’s philosophy of care, locations of treatment centers, and identified staff members. The orientation booklet provided more detail and information about various resources and services:

• Welcome statement
• Clinic philosophy
• Introduction to the cancer care center
• What is cancer
• Preparing for your visit
• Cancer center resources and services
• Clinical trials
• Frequently asked questions
• Summary
• Glossary of cancer terms
• Telephone numbers

Measurements done at baseline included questionnaires regarding awareness of cancer resources and services, demographic information, and state and trait anxiety. Postintervention questionnaires three weeks later measured awareness, use of and satisfaction with services and resources, and state and trait anxiety. Before their first MD appointment, patients were consented and randomized to one of four arms:

• Arm 1: Class—A facilitator showed the video and provided the booklet in class (n = 6).
• Arm 2: Drop-in—Patients were invited to view the video at their convenience and pick up a booklet, without staff teaching (n = 7).
• Arm 3: Mailed home—An orientation package containing the video and booklet was mailed to patients’ homes, without staff teaching (n = 23).
• Arm 4: Control group—An invitation was mailed with preintervention questionnaires and instructions. No video or booklet was provided. Information provided to patients and caregivers was part of routine care (n = 18).

• The study reported on a sample of 54 newly diagnosed patients with cancer and their caregivers.
• Patients were receiving care at a medical oncology clinic.
• Most participants were Caucasian, male, and married.
• Patients had a variety of cancer types; 30% had lung cancers.

Medical oncology clinic

A randomized controlled trial design was used.

• Profile of Mood States (POMS)
• State-Trait Anxiety Inventory (STAI)
• Three tools created by the authors and pilot tested: (a) Awareness and Use of Resources, (b) Coping, and (c) Understanding of the Cancer Center
• T test and Fisher exact tests
• 10% difference to determine clinical significance

• The class arm and drop-in arm had less than 10 participants, and their results were not reported.
• Analyses of effect size (partial eta squared) were conducted to further determine the magnitude of associations rather than only relying on null hypothesis significance testing.
• Exact p values reported: The mailed intervention arm was successful in improving patient outcomes, which was most helpful with high trait anxiety (p = 0.005). Baseline state anxiety of the mail arm was p = 0.003, with follow-up of p = 0.18. Baseline state anxiety of the control group was p = 0.02, with follow-up of p = 0.005.
• Fewer benefits for caregivers were noted.

The study had a small sample size.

The intervention was a formal education/orientation program with oral and written information for patients and their significant others upon beginning radiation therapy. The control group of patients receiving radiation therapy and their significant others received information during their consultation visit via the physician, several pamphlets, and individual teaching by the nurse.

• The study reported on a sample of 100 people (the patient and his or her significant other counted as two people).
• A total of 85 people completed the postintervention assessment: 49 in the intervention group and 36 in the control group.
• All diagnoses and all stages of cancer were included.
• All participants were new to radiation therapy.

A randomized controlled trial design was used.

• State-Trait Anxiety Inventory (STAI)Form Y–State anxiety subscale
• 20-item self-report index
• Profile of Mood States (POMS)–Total Mood Disturbance measure
• 10-item multiple choice test developed for study to measure radiation knowledge

The information orientation session had no significant effect on anxiety, general distress, adherence to treatment, or knowledge about radiation. The program did increase satisfaction with care, use of psychological counseling, and outside support resources.

• The study had a small sample size.
• The study did not report baseline measurements or screening of anxiety prior to intervention.

To examine the effects of preoperative instruction on anxiety levels after gynecology oncology surgery

A random sample of patients scheduled for surgery was selected, and patients were assigned to intervention and control groups. Those in the control group received typical preoperative teaching. The intervention group was informed in detail with written information provided in an interactive situation to patients and caregivers. Instruction included anatomical information, routine preoperative preparation (e.g., removal of dentures, medications for the procedure), and postoperative care (e.g., management of pain, Kegel exercises). Instruction also included information on relaxation and imagery techniques. Study measures were obtained prior to surgery and after surgery immediately prior to hospital discharge.

• N = 120    
• AGE = Median and range were not provided. 50% were older than age 49 years.
• MALES: 0%; FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Ovarian, endometrial and cervical cancers
• OTHER KEY SAMPLE CHARACTERISTICS: 61% had no previous surgical experience.

• SITE: Single site  
• SETTING TYPE: Inpatient    
• LOCATION: Turkey

• PHASE OF CARE: Active antitumor treatment

• Nonrandomized two-group comparative quasiexperimental design

• State-Trait Anxiety Inventory (STAI)

Authors reported STAI-I results and STAI-II results, but it is not clear what STAI-II refers to. STAI postoperative results declined similarly in both groups. STAI-II postoperative results were higher in both groups and increased more in the intervention group than the control group. The difference between postoperative study groups showed overall lower anxiety scores in the intervention group (p = .004).  Baseline anxiety was higher in the control group but not statistically different from the intervention group.

No firm conclusions regarding the effects of the preoperative teaching were given, and conclusions on postoperative anxiety cannot be drawn.

• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (no appropriate attentional control condition)
• Key sample group differences that could influence results
• Measurement validity/reliability questionable
• Other limitations/explanation: Measurement results as reported are unclear. It is surprising that the difference in anxiety scores was greater between groups at baseline but was not statistically significant. However, smaller differences postoperatively were significant. No subgroup analysis was done based on extent of surgery or stage of disease, which could be expected to influence anxiety.

Study limitations preclude the ability to draw any firm conclusions from this research.

Primary aim: To evaluate effect of an educational DVD about chemotherapy on pretreatment anxiety, self-efficacy, unmet informational needs, and satisfaction with information received

Secondary aim: To determine if effects differ between those who perceived treatment to be curative rather than palliative

Control group patients received usual care and completed questionnaires before beginning their treatment. Experimental group patients were recruited at a later time. They were given a copy of the DVD to take home to watch, several days before their first treatment. They then completed questionnaires on the first day of chemotherapy treatment. The DVD focused on preparation for chemotherapy and self-management of side effects, including nausea and vomiting, constipation, diarrhea, mucositis, fever and infection, hair loss, infertility, and effects on sexuality and intimacy. Content was evidence-based, derived from a systematic review of the literature to support recommended self-care approaches. Most content was delivered by cancer survivors who also discussed their experiences and the self-care strategies they used to manage side effects. An oncologist and oncology nurse presented medical and nursing information. The DVD was 25 minutes long and had been previously pilot tested. Usual care education consisted of a brief description of the procedure and side effects provided by the patient’s oncologist and a 30-minute education session with a chemotherapy nurse. Analysis was done within curative and palliative care patient groupings.

• The study reported on a sample of 100 patients.
• Mean patient age among curative cases was 54 years, and among palliative cases was 56.88 years.
• The sample was 52% male and 48% female.
• A variety of cancer diagnoses were represented. The most common types were head and neck, lung, gynecologic, gastrointestinal, and breast cancers.
• A majority of the sample was employed full- or part-time, and patients were essentially equally distributed across educational levels from less than high school completion to university completion.
• The majority of patients were married.
• All patients had not previously received chemotherapy treatment.

• Single site
• Outpatient setting
• Melbourne, Australia

Patients were undergoing the active treatment phase of care.

The study used a prospective quasi-experimental design with use of historical controls.

• Hospital Anxiety and Depression Scale (HADS)
• Cancer Behavior Inventory (CBI)–version 2: 33-item scale used to measure self-efficacy
• Supportive Care Needs Survey (SCNS)–short form: 31 items to assess unmet needs
• Satisfaction with information assessed with four questions on a five-point Likert scale developed for this study

There were no differences in anxiety or depression scores between usual care and intervention groups. Those who watched the DVD rated themselves as more confident about seeking social support than the usual care group (p = 0.044). There were no differences between groups in any supportive care needs that were unmet. Both curative and palliative patients reported having more psychological needs than any other type of care, and reported sexuality as the least needed area. Those in the intervention group were more satisfied with information they had received (p = 0.026) compared to the control group. There were significant differences between self-perceived curative and palliative patients in confidence for maintaining activity (p = 0.028), stress management (p = 0.044), coping with side effects (p = 0.002), maintaining a positive attitude (p = 0.008), managing emotions (p = 0.005), and seeking social support (p = 0.012).

The intervention appeared to have an influence on aspects of self-efficacy and satisfaction with information received. There were no findings to support an effect on anxiety or depression prior to chemotherapy.

• The study did not have an appropriate control group.
• A convenience sample was used.
• The sample size was not sufficiently powered to detect differences in measured outcomes.
• It is not clear how much information provided in the DVD differed from that provided in usual care by chemotherapy nurses and the oncologist.
• While the DVD was a different format, differences in content were not clear. It was also not clear from the report if intervention patients received the DVD in addition to usual care, or instead of usual care.

Prechemotherapy education is an important part of nursing management of these patients, but there is little evidence to guide the timing, content, format, and style of this type of education. Additional research in this area will be helpful to guide nursing practice. The use of adjuncts to direct face-to-face patient teaching and support by nurses may be helpful in the face of workforce shortages and increasing shifts of patient care to suggest that provision of basic information and orientation to the setting are not sufficient approaches to impact feelings of anxiety. Further study of such approaches can be helpful to determine how to best meet patient needs.

To evaluate effects of an electronic-based educational program with knowledge feedback for patients undergoing radiation therapy

Patients scheduled to begin RT were randomized to receive either usual care and education (control group) or usual education and care along with the experimental program. Patients in the experimental group received a link to the program that delivered statements for patient response, demonstrating their knowledge of the general RT process, side effects, self-care, and lifestyle. Patients were given immediate feedback of their knowledge based on responses given to 28 statements. Usual care involved face-to-face education at the time of treatments. Study measures were obtained before beginning RT, after completion of RT, and three months later.

• N = 115
• MEAN AGE = 57.6 (range = 18-75)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All had breast cancer. Significantly more in the intervention had lumpectomy rather than mastectomy
• OTHER KEY SAMPLE CHARACTERISTICS: More than half of the sample had some post-high school education. Eighty percent also were receiving chemotherapy

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: Finland

• PHASE OF CARE: Active antitumor treatment

• Single blind randomized, controlled trial

• State Trait Anxiety Inventory
• Functional Assessment of Cancer Therapy-Breast (FACT-B) for quality of life

Anxiety declined over time in both groups, and showed significant decline between baseline and measures at the end of RT.  Anxiety declined significantly in the experimental group from baseline to three months (p < 00001).  The decline in the control group was not significant, and there was no significant difference between groups.

The education feedback program may help to reduce anxiety in patients receiving radiation therapy, but was not more effective than usual care and education.

• Baseline sample/group differences of import
• Risk of bias (no blinding)

The provision of patient feedback regarding knowledge of treatment and aspects of self-care was delivered in this study via a Web-based program. This might be an effective way to reinforce patient education.

To evaluate the impact of information, provided preoperatively, on the anxiety and knowledge of women undergoing mastectomy for breast cancer; to assess the specific impact of additional, structured preoperative information (delivered by means of educational/informational video) on perioperative anxiety and treatment- and disease-related knowledge in women undergoing mastectomy for breast cancer

Routine information was delivered to both arms of the study. Information was not standardized and included the typical conversation with the attending surgeon, surgical informed consent, and practical information from nurses. The treatment arm provided additional information delivered preoperatively via video; the information was recorded by a breast cancer survivor. Information in the video was obtained from the National Cancer Institute’s website. All patients were prospectively followed for one month (further follow-up was performed according to local treatment protocols) at 24–36 hours, 7 days, and 30 days postoperatively.

• The study reported on a sample of 58 female patients.
• Mean patient age was 60 years in the intervention group and 55 years in the control group.
• Patients had a diagnosis of breast cancer needing mastectomy, with cytologically or histologically proven invasive breast cancer. More than 80% in both arms had IIA and IIB stage disease, and 76% were diagnosed with ductal carcinoma.
• Women were older than 18 years of age and had the physical and psychological ability to use a visual analog scale and to complete requested questionnaires.
• Women were excluded from the study if they were admitted for breast-conserving therapy, neoadjuvant treatment for breast cancer, disseminated breast cancer, vision and/or hearing impairment, previous treatment for other malignancies, medical education, and other factors (geographical and familial) that would interfere with the protocol requirements.

• Inpatient
• Department of Surgical Oncology, Maria Sklodowska-Curie Memorial Institute of Oncology, Krakow, Poland

• Phase of care: active treatment
• Clinical applications: late effects and survivorship

Open-labeled, randomized controlled trial

• To measure anxiety: A visual analog scale (VAS) for anxiety was validated and shown to be the clinical equivalent of the Hospital Anxiety and Depression Scale (HADS) and the State-Trait Anxiety Inventory (STAI).  
• To measure level of knowledge: Investigators used a VAS (a subjective measure) as well as a self-administered questionnaire (an objective measure) containing specific questions about breast cancer treatment and familial risk.

• Authors noted no significant differences in anxiety levels between the intervention and control arms over all four time points.
• Authors noted no significant differences in subjective or objective knowledge between the intervention and control arms over all four time points.
• The number of patients confirming the association of the participant’s disease with an elevated risk for breast cancer in children or close blood relatives increased in the intervention arm from 40% preoperatively to 70% postoperatively.

Patients who participated in the study showed no evident or significant improvement in perioperative anxiety or treatment- and disease-related knowledge, with the exception of knowledge concerning available primary treatment modalities.

• The study had a small sample size, with fewer than than 100 participants.
• The outcomes of this study may result from having no a priori sample size estimation or power analysis. Interpreting results was difficult.

Patient education, as well as emotional support, should always be important preoperatively and must continue postoperatively.