Psychoeducational and Psychological Distress Levels in Women with Breast Cancer: A Systematic Review

Dewi Mustikaningsih1,2* Yan Wisnu Prajoko1, Anggorowati Anggorowati1, Angga Wilandika2, Shella Febrita Puteri Utomo2, Ridwan Maulana Alamsyah2

1Doctoral Study Program of Medical and Health Sciences, Faculty of Medicine, Diponegoro University, Semarang, Central Java, 50275, Indonesia

2Department of Nursing, Faculty of Health Science, ‘Aisyiyah University Bandung, Bandung, West Java, 40264, Indonesia

*Corresponding Author’s Email: dewi.mustikaningsih@unisa-bandung.ac.id

ABSTRACT

Background: Psychoeducation has become a popular intervention for women who have been patients with breast cancer (BC). The effectiveness of psychoeducation on the psychological distress levels of patients with breast cancer was assessed in this systematic review comparison. The aim is a systematic review to assess the effects of psychoeducation on anxiety and depression in women with BC diagnoses. Methods: The Cochrane Library, Ebsco, Embase, and PubMed databases were used for RCT data collection, using various keyword combinations such as "psychoeducation," “breast cancer diagnosis," "anxiety," "depression," "psychological distress," and randomized controlled trial." Only papers focusing on interventions related to psychoeducation and psychological distress in patients with BC diagnoses were collected. Furthermore, the inclusion criteria include breast cancer women over 18 years of age who have had breast cancer diagnosis. The selected articles were all published between 2001 and 2022. Results: A total of 2,181 participants from fifteen RCTs (1,158 psychoeducation and 1,023 controls) were included. The risk of bias (ROB) study used the Joanna Briggs Institute (JBI) for RCT, with results in the 89.74% good category. Analysis data will describe characteristic studies, ROB, and outcome psychoeducation. Psychoeducation significantly decreased the psychological distress level associated with BC diagnosis when compared to controls. Conclusion: Psychoeducation has the potential to be used as an intervention to assist patients in their pathways of primary breast cancer treatment aftersurgery. It was discovered that psychoeducation lowers psychological distress, which benefits the patients.

Keywords: Breast Cancer Diagnosis; Psychoeducational; Psychological Distress; Systematic Review

INTRODUCTION

Patients with primary breast cancer who undergo surgery report higher levels of anxiety and despair due to the trying experience (Martinez-Calderon et al., 2024). Most breast conditions are not cancerous, encompassing various types of histological conditions which can be categorized into non-proliferative, proliferative without atypia, and proliferative with atypia (Saleem, Javed, & Ahmad, 2020). According to an Australian cohort study based on population involving 22,505 cancer patients and 244,000 cancer-free adults, cancer survivors who had mastectomies reported higher levels of psychological distress than those without mastectomies (Joshy et al., 2023). Furthermore, the amount of meta-analysis research on depression and anxiety worldwide is likewise substantial (Martinez-Calderon et al., 2024), the study by Civilotti and colleagues found that 25% of patients showed substantial depression symptoms and that 40% of mastectomy patients showed clinically significant anxiety symptoms (Civilotti et al., 2021). Šimunovic's study also revealed that individuals undergoing radical mastectomy procedures had stressor levels 19% greater than those undergoing partial mastectomies (Šimunović & Ljubotina, 2020). These results imply that thelives of mastectomy patients must be impacted by the stress management that they experience (Ticha & Sukop, 2023). Patients who have undergone a mastectomy have to endure the stress, which will lower their quality of life, and physical impairment (Kim et al., 2021).

Anxiety and depression were linked to mortality and survival based on the conclusions of a thorough study and meta-analysis of 51 cohort studies (Wang et al., 2020). The impact of psychological distress on post-mastectomy breast cancer women is indicated by symptoms of disturbed anxiety, depression, pain, self-esteem and body image (Varman et al., 2024). Additional effects of psychological strain following a mastectomy include a 63% decline in self-esteem about one's body image, a 51.8% change in lifestyle, a 58% sense of worthlessness, and a 75% sense of receiving less care (Anim-Sampong et al., 2021). Therefore, the stress experienced post-mastectomy-procedure affects the psychological aspects. As a result, psychoeducational intervention is required to eliminate and prevent those risks from reoccurring. Adequatepsychoeducational intervention is significant in reducing the stress level of post-mastectomy patients. Various psychoeducational interventions have been carried out for patients suffering from this kind of stress; the results, however, are varied (Boesen et al., 2011). Furthermore, psychoeducational interventions in numerous developing nations, including Indonesia, are not successful in lowering post-mastectomy stress (Boesen et al., 2011). Stress management in post-mastectomy patients is associated with oncologists, nurses, and psychologists providing psychoeducational interventions as psychosocial treatment (Sağdıç, Bozkul & Karahan, 2024). Nurses serve as educators by sharing knowledge and offering psychological support to lower post-mastectomy stress levels. This psychosocial intervention refers to psychological and social interventions that help nurses manage psychological and social components and their effects on patients' health and quality of life while maximizing physical health care (Oakley & Ream, 2024). Treatment of psychosocial needs includes services and interventions, ranging from interventions with direct nursing actions to educational interventions (Travado & Bastos, 2024). Numerous studies have proven that psychosocial interventions could benefit patients, so these interventions ought to be incorporated into physical care (Oakley & Ream, 2024). This systematic review aims to evaluate the effects of psychoeducation on depression and anxiety in women with BC diagnosis.

METHODOLOGY

Data Sources and Search

The authors admitted to the recommended Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) requirements in organizing, conducting, and reporting this review. The authors thoroughly searched from 12 February 2022 in the PubMed database, Embase.com, Cochrane Libraries, and Ebsco. The key terms we want to include in our search have been identified using the PICO model below: P (patient/client group): breast cancer patients over 18 years of age who have had a breast cancer diagnosis. I (intervention): psychoeducation; C (comparison): usual form of treatment or no intervention; O (results): psychological distress. The terms psychoeducation, diagnosis, and breast cancer are utilized as index terms or word- free text, along with their synonyms and close relatives. This research method uses a systematic review approach, namely evaluating the impact of psychoeducation on the level of psychological distress in breast cancer patients, so there is no ethical clearance in this research. References from identified articles are used for searching pertinent literature. A comprehensive search plan for all databases is provided in Figure 1.

Cochrane Results (12 February 2022)

PubMed Session Results (12 February 2022)

Embase Results (12 February 2022)

Ebsco Results (12 February 2022)

Figure 1: The Search Strategies

Study Selection and Data Extraction

To filter articles, the authors used the Mendeley web application and the search feature in the database. Three reviewers (DW, YW, and AW) manually rejected irrelevant studies afterusing search and reference methods to screen the identified articles. The abstracts of the remaining papers were then independently reviewed for compliance with the inclusion criteria. Reference checks were also carried out. Any disagreement with the two authors (AG and SU) was resolved through discussion amongst the parties. If consensus could not be reached, the authors turned to experts for definitive answers to the final decision. Studies were considered if they matched the following standards: The participants were breast cancer patients (defined as individuals diagnosed with breast cancer), and the RCTs were peer-reviewed scientific articles published in English. There were studies that looked at psychosocial interventions with a main focus on psychoeducation, such as health education, self-help, and self-management interventions. There were also studies with controls that got standard care, standard treatment, or were put on a waiting list. Finally, there were studies that at least said one of the following: "Breast cancer awareness (here defined as the patient's knowledge of breast cancer) was evaluated using a knowledge test that included. The psychoeducational intervention may require a lot of time to carry out. The authors gathered the following information: Women diagnosed with breast cancer serve as both participants and recruits, as well as the intervention and group (psychoeducational approach and control group). The authors independently verified every piece of detailed information. A consultation with experts was carried out to conduct a systematic review, and the following outcome datawere independently gathered: characteristic studies and outcome psychoeducation.

Eligibility Criteria

Article analysis was obtained from articles published from 2001 to 2022. The research team initially screened articles by reading titles and abstracts and then reviewed all relevant texts of the articles to determine their eligibility for inclusion. The inclusion criteria consisted of articles that (1) focused on diagnosed breast cancer women over 18 years of age who have had breast cancer diagnosis; (2) psychological or psychoeducational interventions; (3) measurement of psychological distress, anxiety, and depression; and (4) included the original study with a randomized controlled trial method. The exclusion criteria applied are as follows:(1) articles that focus on psychoeducation with other health problems; (2) other psychological interventions; and (3) literature review, dissertation, editorial, commentary, and other expert opinion.

RESULTS

Study Selection and Inclusion

A total of 249 papers were discovered throughout the literature search: 103 on PubMed, 109 on Embase.com, 36 at APA PsycINFO, and one at the Cochrane Library. Forty-six articles were selected for full-text evaluation after removing any duplicates and screening the titles and abstracts, and the systematic review finally included 15 research studies (Figure 2).

Figure 2: PRISMA Flow Chart for the Article Selection

Characteristics of the Included Studies

There were 2,181 individuals in total across the 15 studies (1,158 in the intervention group and 1,023 in the control group). The characteristics chosen from the included studies are summarized in Table 1. Patients diagnosed with breast cancer who underwent primary or postoperative curative treatment were included in the 15 studies. Of the 15 investigations, participants were chosen based on the clinical context. These studies were conducted by high- income countries (n = 15) (HIC). Eight studies in the control group compared the waitlist with conditions typical of the control group, and four compared psychoeducation with routine care. Regarding the length of intervention, six studies on interventions lasted for eight weeks or longer, and another six studies on interventions required a shorter time.

One study should have reported the number of intervention and control group participants. Seven studies aimed to find group formats for psychoeducation, whereas the other five aimed to find individual formats. Regarding professional support, most of the studies (15) viewed assistance from third parties as psychoeducation provided or assisted by one or more specialists. Most studies (10) used in-person psychoeducation; the remaining two used digital media (video). Following surgery, postoperative psychoeducational material for women with primary breast cancer includes: (a) knowledgeof breast cancer, such as medical conditions and treatments (5 studies); (b) treatment of patients with breast cancer (7 studies); (c) adherence to nutrition recommendations (1 study); and (d) psychosocial support using resources (7 studies). The outcomes of anxiety (9 studies), depression (10 studies), knowledge (1 study), dietary adherence to nutrition (1 study), pain (1 study), and fatigue (1 study) were all examined.

Table 1: Characteristics Studies

BC: Breast cancer; BDI: the Beck Depression Inventory-II; CES-D: the Centre for Epidemiological Studies of Depression; BSI: the Brief Symptom Inventory; EORTC-QLQ-C- 30: the Quality of Life Questionnaire developed by the European Organisation for Research and Treatment of Cancer; FACT: the Functional Assessment of Cancer Therapy; FACT-B: the Functional Assessment of Cancer Therapy for the Breast Questionnaire. HIC: High-income countries; LIMIC: Low-and Middle-Income Countries; HADS: Hospital Anxiety and Depression Scale (HADS); POMS: Profile of Mood States; Questionnaire knowledge; NRS: numeric rating scale; STAI: State-Trait Anxiety Inventory; BRIEF-COPE; MOS SF-12: QOL; and CBA-OE.

Risk of Bias (ROB)

The Joanna Briggs Institute (JBI) utilizes the Risk of Bias (ROB) tool to assess the potential for bias in randomized controlled trials (RCTs), enhancing the reliability and validity of study results (Joanna Briggs Institute, n.d.).

Synthesis of Results

The data based on the synthesis related to shown in the results of the effectiveness psychoeducation (table 2).

Table 2: Summarized Results of the Reviewed Studies

DISCUSSION

This systematic review aims to discover the role of psychoeducation and its affect individuals receiving an initial breast cancer treatment following surgery. The effects of psychoeducation in reducing the levels of anxiety and depression in contrast to medical recommendations from first-time admissions of patients undergoing primary therapy following breast cancer surgery are the subject of the first systematic study. Only three studies included outcomes for anxiety and depression (Stanzer et al., 2019), which could account for the absence of detectable benefits. Symptomatic breast cancer patients, diagnoses, and survivors were examined in a recent study (Setyowibowo et al., 2022), demonstrating that psychoeducation can significantly reduce anxiety. The findings of another nine additional studies might also be included, similar to reducing other psychological issues. Since the groups were not initially equalized in terms of several psychological characteristics, similar to two previous trials on psychoeducation, the psychoeducation did not significantly reduce depression. It also did not improve psychological discomfort when combined with group psychotherapy (Boesen et al., 2011).

Our research shows that following surgery, psychoeducation can help patients with primary breast cancer feel less anxious (Stanzer et al., 2019), and it is consistent with a prior meta- finding analysis stating that psychoeducation has a beneficial effect on reducing the level of anxiety in patients with breast cancer symptoms and breast cancer survivors (Setyowibowo et al., 2022). According to past studies, psychoeducation can help patients learn strategies to manage stress, improve their understanding of coping processes, not feel lonely, and find consolation through social support (breathing and relaxation exercises). In contrast to a previous meta-analysis of patients with breast cancer revealing a positive benefit of digital/video-based psychoeducation, the authors discovered that no beneficial effect on depression could be gained from it (Stanton et al., 2005). The interventions primarily emphasized arousal and stress-reduction strategies (such as relaxation exercises), which ignored common depression symptoms, including melancholy feelings and exhaustion. This may be thecause of the lack of psychoeducational effectson depression. Behavioural activation is more helpful in reducing depression symptoms (Stanton et al., 2005). Intriguingly, a subgroup analysis revealed that the methods of psychoeducation (in-person or online) had varied impacts on reducing depression, with the face-to-face format showing the most significant reduction in depression. Due to the utter differences in study sample sizes (n = 2 digital comparison versus n = 13 no digital), these results should be regarded with caution. Video-based interventions are a subset of digital interventions. This can be partially explained by the slightly higher dropout rate for digital psychoeducation (up to 33%) compared to psychoeducation conducted in person (up to 24%). A typical issue with e-health initiatives is that they have gradually become more ineffective (Stanton et al., 2005).

Additionally, it is more practical to try to add psychoeducation to the regularly provided psychosocial care in hospitals instead of providing it digitally or remotely for patients subject to primary care. Another reason for the decreased effectiveness of digital psychoeducation delivery could be that only some patients receiving primary care after surgery, primarily middle-aged women, have the best digital skills. However, it should be highlighted that prior meta-analyses did not reveal any evidence of variations in the efficacy of guided self-help and in-person therapies for depression (Stanton et al., 2005). In addition, self-help interventions, both individually and face-to-face, typically require more time and money (Setyowibowo et al., 2022). Patients with cancer have received psychoeducation in various digital formats (Setyowibowo et al., 2022), and this remains a worthwhile idea that requires additional investigation.

Another subgroup result showed that eight psychoeducational sessions had a better effect on reducing anxiety than fewer sessions. From a dose-effect standpoint, it is unsurprising that longer interventions produce a more potent interaction. It is essential to balance providing the best and most effective level of psychoeducation while maintaining its applicability and acceptability to specific patients. Afterall, adding more sessions means adding more effort and resources. A study with ten sessions was also undertaken. However, its results did not reduce the chance of developing breast cancer due to the low number of sessions in that one study (Stanton et al., 2005).

A helper assists (or guides) various health professionals as they provide psychoeducation in this manner. This diversity hampers statistical comparisons between various categories of healthcare professionals. Regarding anxiety and sadness, however, the authors tried to discover the differencesin the impact of psychoeducation provided or assisted by specialists from single disciplines vs. those from multiple disciplines. In neither of these outcomes, this subgroup analysis found any distinction between psychoeducation provided by specialists from single disciplines or multidisciplinary teams. Furthermore, the authors found no differences between psychoeducation on anxiety and depression delivered within a cognitive-behavioral therapy framework and other forms of psychoeducation.

More than 15 randomized clinical trials showed that psychoeducation significantly reduced psychological distress. In 2021, research revealed that psychoeducation effectively enhanced adaptive coping strategies, and patients who received psychoeducation could use adaptive coping strategies afterjoining theprogram with significantly higher levels (Younis, Norsa’adah & Othman, 2021). Research by Cipolletta and colleagues also found that psychoeducation shows psychological changes such as decreased anxiety and depression and positive changes in increased perception (Cipolletta, Simonato, & Faccio, 2019). Research by Dastan and colleagues shows that psychoeducation has also proven positive in causing changes in the level of adjustment to cancer (Dastan & Buzlu, 2012). Research by Wu and colleagues in a systematic review reported that nonpharmacological interventions were effective at reducing fatigue levels (Wu et al., 2019). Psychological interventions such as psychoeducation significantly reduced fatigue at the treatment stage for cancer patients. These results emphasized more the aspects of psychoeducation that are proven helpful to reduce depression, anxiety, and depression in breast cancer patients diagnosed.

CONCLUSION

This analysis demonstrates the potential of psychoeducation as an intervention to assist patients in their primary breast cancer treatment pathways after surgery. This systematic review also showed that psychoeducation to reduce the symptoms of anxiety and despair, mainly when delivered over a long period of time and in person, was effective in enhancing the quality of life. It was discovered that psychoeducation has an impact on lowering psychological distress.

Recommendations

Recommendations for further research suggest that this psychoeducational intervention can be applied to patients diagnosed with breast cancer who are undergoing medical treatment such as mastectomy, chemotherapy, radiotherapy, or other treatments for survivors.

Conflict of Interest

The authors have no apparent conflicts of interest.

ACKNOWLEDGEMENT

The authors are thankful to Hibah Riset-Muh Majlis Dikti Muhammadiyah for providing funding for this investigation.

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