Impact of cancer on everyday life: a systematic appraisal of the research evidence

Abstract

Objective  To conduct a systematic appraisal of the published literature reviews related to the impact of cancer on everyday life. This theme was identified as the top priority area for research by participants in the Macmillan Listening Study, which was the first UK‐wide public consultation exercise to identify patients’ priorities for cancer research.

Search strategy  The top priority area was divided into ten sub‐themes, and a modified systematic review was undertaken for each sub‐theme using electronic searches.

Inclusion criteria  Literature review papers were included if they were written in English, involved patients diagnosed ≥18 years, any cancer types and published between 2000 and 2006.

Data extraction and synthesis  Two thousand and two hundred and fifty‐two potentially eligible papers were identified. Abstracts were read by the first author and selected for inclusion in the review. Twenty percentages of the papers were also read independently by other authors. Sixty‐two review papers were finally selected.

Main results  The systematic appraisal revealed that some sub‐themes of the patient‐identified priority area (e.g., how to support family members of cancer patients) were under‐researched, while other sub‐themes (e.g., anxiety and depression experienced by cancer patients) had been explored to some extent. Certain areas of research interest to patients were found to have been explored; however, their significance was limited by the quality of the research.

Conclusion  The systematic appraisal highlights important areas for future research and the need for more effective dissemination of study findings to wider audiences, including service users. This study also indicates the need for further research to enhance the generalizability and/or significance of findings.

Introduction

The purpose of this study was to conduct a systematic appraisal of the published literature reviews related to the impact of cancer on everyday life and provide greater detail of this area drawing on current research evidence.

‘The impact of cancer on everyday life’ was the top priority area identified by participants in the Macmillan Listening Study, a UK‐wide public consultation exercise to identify patients’ priorities for cancer research. ¹ This study enabled the effective involvement of service users to occur at all stages of the study. Involving service users in setting the research agenda is particularly important as earlier studies have shown that their priorities may differ from those of academics or clinicians. ² , ³ , ⁴ In cancer research, the involvement of patients in determining priorities for research has remained under‐developed. ⁵

In the Listening Study, people affected by various types of cancer, different stages of treatment and varied age were participated in consultation groups held at ten locations across the UK. Research ideas generated in the consultation groups were shared with other participants and clustered into themes by the group, after which participants voted on areas of importance. (Refer to Corner et al. ¹ , ⁵ for a detailed account of research methods and analysis). As a result, patients identified fifteen broad priority areas for research. ⁵

To take forward the findings of the study and inform funding decisions, it is necessary to review recent research activity for each patient‐identified priority area. This systematic appraisal focused on the top priority area, ‘the impact of cancer on everyday life’, and identified research areas within the top priority area (i) that have already been explored in research, (ii) that remain under‐explored, thus suggesting potentially fruitful areas for future academic enquiry, and (iii) that have been explored before but still need further research for more conclusive results because of methodological limitations with primary studies.

To review recent research activity for the top research priority area, which is itself broad in scope, an approach to appraising literature was adopted that allowed diverse and broad subject areas to be reviewed without compromising rigour, transparency and repeatability.

Methods

Standard systematic reviews typically take between 6 and 18 months to complete. ⁶ Given the breadth of research interests that constitute the top priority area, it was not feasible to undertake a systematic review for all ten sub‐themes derived from the top priority area (See below for the sub‐themes). Consequently, a systematic review process was modified to enable a rigorous, transparent and reproducible appraisal of the literature to be completed within the timescale available. This approach broadly follows the rationales and principles of scoping reviews discussed by Arksey and O’Malley. ⁷

The following systematic review principles were retained: identifying search engines; formulating search terms; generating inclusion and exclusion criteria; and reviewing abstracts independently. However, the systematic appraisal focused on published literature review papers only rather than primary research papers and did not require a formal process for data extraction or an assessment of quality of literature review. By focusing on review papers, it was possible to explore a broad range of primary research studies. The quality of each literature review paper was not assessed as a broad range of research evidence was sought; therefore, any types of literature review papers, such as review articles that had not undertaken a formal literature review process (e.g., using search engines), were included. However, the thoroughness of each review paper was taken into consideration when using the conclusions of the reviews.

Research sub‐themes for the systematic appraisal

Within the top research priority area, questions and ideas generated by participants in the Macmillan Listening Study were examined and grouped into ten sub‐themes to enable the systematic appraisal to focus on specific aspects of the top priority area. The following shows the ten sub‐themes and the research interests within each identified by the Listening Study participants:

• 1 Psychological impact of cancer from the point of diagnosis
  •    • The psychological impact of cancer on patients and strategies to cope with psychological problems
• 2 Impact of cancer on family and friends
  •    • The psychological impact of cancer on partners, family and friends
• 3 Impact of positive mental attitudes/stress on recovery and survival
  •    • Influence of one’s positive mental attitude or stress on a patients’ chance of recovery and survival
• 4 How to improve mental attitudes
  •    • How to improve mental attitudes and how to cope with uncertainty while living with cancer
  •    • Effects of particular interventions (e.g., visualization or meditation) on patients
• 5 Impact of aftercare on patients
  •    • The extent to which follow‐up services met the needs of those affected by cancer
  •    • The extent to which support provided after treatment impacts on the lives of patients
• 6 Impact of cancer on patients’ social functioning
  •    • How cancer impacts on patients’ lives, preventing them from sleeping, travelling, driving, shopping, taking part in recreational activities, etc., and how this can be managed
• 7 Impact of pain on quality of life
  •    • The potential impact that pain has on the quality of life of cancer patients
• 8 Role of diet in managing cancer
  •    • The role of diet in the management of cancer and effect of healthy diet on survival
• 9 Effect of living with a partner or a family on recovery
  •    • Benefits of living with a partner or family in terms of cancer recovery
• 10 Relationship between lifestyle and survival
  •    • The relationship between a healthy lifestyle (e.g., exercise) and cancer survival

Search strategy

The following electronic databases were searched: BNI (British Nursing Index), CINAHL (Cumulative Index to Nursing and Allied Health Literature), EMBASE, Medline, PsycINFO, Web of Science, PubMed, and Cochrane. The database search included papers and literature reviews (systematic, comprehensive, or other) written in English. Literature review papers were identified by examining the title and abstract of each paper, and types of reviews were classified according to papers’ title and/or methodology. Review papers concerning all cancer types published between 2000 and 2006 were included. Examining literature reviews published during this time frame enabled findings to be based on evidence from primary studies conducted over a longer period. Papers were excluded if they involved childhood and adolescent cancers because this was categorized within the Macmillan Listening Study as a separate research priority area. Papers that were biomedical in focus (e.g., drug trials), retrospective data reviews, reviews of treatment outcomes, or reviews of an individual patient case were also excluded.

Systematic appraisal process

The systematic appraisal was conducted in two stages: scoping exercise and literature review.

The aim of the scoping exercise was to refine search terms by examining abstracts and key words obtained as a result of a literature search undertaken on each sub‐theme using the electronic databases and inclusion/exclusion criteria. Initial search terms were identified with reference to the Macmillan Listening Study findings.

Search terms refined by the scoping exercise were used to conduct literature review for each sub‐theme. (The search terms used for the literature review are available from the authors on request.) The same electronic databases were used, and search results were screened in three stages. First, the title and abstract of each paper was read by IO, when duplicates and papers that were not review articles were excluded. Secondly, papers which met the exclusion criteria and which had no abstract were excluded, and papers considered more relevant to other sub‐themes were removed from the original source and added to the other sub‐themes by IO. In this stage, 20% of the papers were also reviewed in the same way by DW and CF independently. Differences were resolved by consensus, and reasons for rejecting papers were recorded. Lastly, selected papers were retrieved and read by IO, and irrelevant ones were excluded by consensus.

Results

A total of 62 review papers were selected. The number of review papers identified for each sub‐theme is illustrated in Table 1. Types of review papers included in the study are shown in Table 2.

Table 1.

 The results of the systematic appraisal

	Sub‐theme	Total number of abstracts identified by literature review	Number of abstracts excluded (not review papers; duplicates)	Total number of abstracts (a)	Number of excluded abstracts (b)			Number of retrieved papers from own sub‐theme (a) − (b)	Number of papers from other sub‐themes (c)	Total number of retrieved papers (a) − (b) + (c)	Number of retrieved papers excluded (d)	Number of papers used in the study (a) − (b) + (c) − (d)
					Met exclusion criteria	Abstract not available	Abstracts relevant to other sub‐themes
1	Psychological impact of cancer from the point of diagnosis	13 020	12 302	718	628	36	36	18	9	27	20	7
2	Impact of cancer on family and friends	3410	3236	174	148	7	3	16	19	35	24	11
3	Impact of positive mental attitudes or stress on recovery and survival	576	551	25	17	1	5	2	14	16	8	8
4	How to improve mental attitudes	3020	2950	70	54	5	8	3	19*	22	8	14
5	Impact of aftercare on patients	2415	2081	334	300	8	5	21	9	30	27	3
6	Impact of cancer on patients’ social functioning	1697	1598	99	83	2	12	2	6	8	6	2
7	Impact of pain on quality of life	5441	5098	343	317	14	10	2	2	4	3	1
8	Role of diet in managing cancer	2823	2572	251	243	1	5	2	2†	4	0	4
9	Effect of living with a partner or a family on recovery	2973	2832	141	135	2	3	1	1	2	0	2
10	Relationship between lifestyle and survival	1477	1380	97	84	4	1	8	13	21	11	10
	Total	36 852	34 600	2252	2009	80	88	75	94	170	108	62

*Three papers used in Sub‐theme 3 and 1 paper used in Sub‐theme 1 were included.

†Two papers used in Sub‐theme 10 were also used in this sub‐theme.

Table 2.

 Types of review papers included in the study

	Sub‐theme	Systematic review	Cochrane review	Literature review	Conceptual and empirical review	Structured review	Comprehensive review	Critical review/analysis	Integrative review	Meta‐analysis/meta‐analytical review	Literature review without database searches	Total
1	Psychological impact of cancer from the point of diagnosis	2	0	4	1	0	0	0	0	0	0	7
2	Impact of cancer on family and friends	1	1	5	1	0	0	2	1	0	0	11
3	Impact of positive mental attitudes or stress on recovery and survival	2	1	2	0	0	0	0	0	1	2	8
4	How to improve mental attitudes	3	2	4	0	0	0	1	1	2	1	14
5	Impact of aftercare on patients	1	1	0	0	1	0	0	0	0	0	3
6	Impact of cancer on patients’ social functioning	0	0	2	0	0	0	0	0	0	0	2
7	Impact of pain on quality of life	0	0	0	0	0	0	1	0	0	0	1
8	Role of diet in managing cancer	0	0	3	0	0	0	0	0	0	1	4
9	Effect of living with a partner or a family on recovery	1	0	0	0	0	0	0	0	0	1	2
10	Relationship between lifestyle and survival	4*	1	4	0	0	1	0	0	0	0	10
	Total	14	6	24	2	1	1	4	2	3	5	62

*Two ‘systematic review and meta‐analysis’ papers included.

Sub‐theme 1: psychological impact of cancer from the point of diagnosis (seven review papers identified)

According to a conceptual and empirical review on post‐traumatic stress disorder (PTSD) following cancer, a significant proportion of cancer patients suffer PTSD symptoms, ⁸ and a literature review on studies of psychological aspects of lung cancer showed that lung cancer patients have a high risk of psychosocial problems after diagnosis and treatment. ⁹ One of the findings of a systematic review on depression in patients with advanced cancer and amongst mixed hospice populations was that approximately 15% of palliative care inpatients experienced major depression. ¹⁰

Regarding the impact of anxiety over the clinical course of prostate cancer, a systematic review reported that anxiety levels associated with cancer appeared to fluctuate during the course of treatment in patients, ¹¹ and a similar trend was also found by a literature review on psychological functioning in cancer patients treated with radiotherapy. ¹² Two literature review articles on age differences in psychological impact of cancer showed that the detrimental psychological impact of cancer was less pronounced in older patients than it was in younger patients; ¹³ , ¹⁴ however, the results were not conclusive because of methodological limitations within each primary study.

Other review papers also identified methodological limitations within each primary paper, including small sample size ¹⁰ , ¹¹ or low participation rate. ¹⁰ In many primary studies, depression was measured on a variety of scales, making comparison across populations difficult. ¹¹ , ¹² , ¹⁴ These need to be considered when interpreting the results.

The systematic appraisal revealed that the psychological impact of cancer has been studied to a large extent; however, it did not identify reviews regarding everyday emotional and psychological aspects of having cancer and strategies patients can use to manage these problems in everyday life.

Sub‐theme 2: impact of cancer on family and friends (11 review papers identified)

According to a conceptual and empirical review on the psychosocial aspects of parental cancer in adulthood, a sizable minority of adult children of cancer patients experience psychological distress in terms of anxiety, depression and post‐traumatic stress symptoms. ¹⁵ Similarly, a literature review on psychological well‐being in families of elderly cancer patients revealed that their relatives were confronted with physical as well as psychological impairment (i.e., fatigue, sleeping disorders, headache, anxiety and feelings of uncertainty, depressive reactions, hopelessness and helplessness) and that their healthy partners were also exposed to specific stressors requiring significant adaptations. ¹⁶

Evidence from studies in another literature review also showed that providing care has an enormous impact on caregivers’ quality of life. ¹⁶ , ¹⁷ In an integrative review on the psychological responses of spouses whose husbands have undergone prostatectomy, it is highlighted that spouses experience both short‐ and long‐term distress because of their caregiving roles. ¹⁸ In terms of partners’ adjustment to breast cancer, however, a critical analysis of intervention studies indicated that despite the considerable descriptive research documenting the need for partner interventions, none of the studies they reviewed were sufficiently rigorous methodologically to enable firm conclusions to be drawn. ¹⁹

In terms of the impact of parental cancer on children, a literature review showed two different views; quantitative studies reported disturbed emotional functioning, while qualitative studies reported problems in emotional, social, behavioural, cognitive and physical functioning. ²⁰ Another literature review also reported considerable emotional burden for families and children of young women with advanced breast cancer, and their emotional adjustment and needs were affected by the developmental stage of the child. ²¹ In terms of improving communication with children and adolescents about a family member’s cancer, a Cochrane review concluded that there have been a few reported studies in this area, and the evidence was weak to suggest that some interventions, such as structured group interventions, may lead to improvement in knowledge and understanding, in coping, anxiety, adjustment and well‐being. ²²

These results, however, should be read with caution owing to methodological limitations within each primary study. Most caregiver studies have examined homogeneous populations such as convenience samples of middle‐ and upper‐class White women coping with maternal breast cancer. ¹⁵ Moreover, most studies of the caregiving process are cross‐sectional in design, and longitudinal studies involving patients and their caregivers are necessary to evaluate caregivers’ psychosocial outcomes according to changes in their role and the course of patients’ disease. ¹⁵ , ¹⁶ , ¹⁷ A lack of comparison groups also limits the strength of the association between caregivers’ emotional distress and the experience of their family member’s cancer. ¹⁵ , ¹⁷ Using generic quality of life (QOL) instruments with caregivers can also be problematic because some items are not relevant to caregivers. ¹⁷

Although there are a number of studies on the impact of cancer on family caregivers, how to support them has received little attention. ²³ , ²⁴ , ²⁵ Furthermore, no review paper on the impact of cancer on friends of cancer patients was identified.

Sub‐theme 3: impact of positive mental attitudes/stress on recovery and survival (eight review papers identified)

Numerous studies have been conducted in this area; however, according to a systematic review and a literature review on influence of psychological coping on survival and recurrence in cancer patients, there is little evidence in this subject. ²⁶ , ²⁷ Similarly, another literature review concluded that there is no convincing evidence to demonstrate that psychological factors affect the initiation or progression of cancer. ²⁸ There has been a systematic review, a Cochrane review, a meta‐analysis, and two literature reviews on the effect of psychological interventions on cancer patients’ survival; however, no firm conclusions could be drawn about this subject. ²⁹ , ³⁰ , ³¹ , ³² , ³³

To make progress in this field of research, further research with sound methods is needed for more conclusive results.

Sub‐theme 4: how to improve mental attitudes (14 review papers identified)

Lin and Bauer‐Wu ³⁴ concluded in their integrative review that patients with an enhanced sense of psycho‐spiritual well‐being are able to cope more effectively with the process of terminal illness and to find meaning in living with cancer and that psycho‐spiritual well‐being can be enhanced by prognostic awareness, family and social support, autonomy, hope and meaning in life.

Our systematic appraisal also demonstrated that there have been many intervention studies conducted in this area. For example, a literature review reported that interventions on patients’ psychological well‐being were not consistently effective, ³¹ while another literature review suggested that psychosocial interventions could reduce the degree of depression for lung cancer patients. ⁹ According to a Cochrane review, some evidence for short‐term psychological benefit was observed in some interventions, such as group psychological therapy for women with advanced breast cancer, but in general these were not maintained even to a few months of follow‐up. ³³ Similar results with adult cancer survivors were also reported in a meta‐analysis. ³⁵ One of the findings of a systematic review of psychological therapies for cancer patients was that interventions, such as group therapy, education, counselling and cognitive behavioural therapy, might have longer‐term benefits for psychosocial outcomes, although the methodological quality of most of the trials that were reviewed was less than optimal. ³²

In terms of the effectiveness of treatment of depression during cancer care, there is no strong conclusion about the effectiveness of antidepressants or psychological interventions for improving depression outcomes; ³⁶ however, this is from a less structured review article, in which the review process was unclear.

Three reviews were identified relating to relaxation training. A meta‐analytical review of randomized intervention‐control studies on the effectiveness of relaxation training showed that relaxation training proved to have a significant effect on emotional adjustment variables, depression, anxiety and hostility. ³⁷ A critical review of studies on the use of mindfulness meditation interventions (one of the mind–body therapies with primary emphasis on experiencing life fully and being in touch with the full range of human emotions and sensory experience) reported that mindfulness meditation improved psychological and physical symptoms in cancer patients. ³⁸ In a systematic review of literature on the effectiveness of Mindfulness‐Based Stress Reduction (a specific, highly structured psycho‐educational and skill‐based therapy package that combines mindfulness meditation with hatha yoga exercises) for cancer supportive care, MBSR was found to have potential as a clinically valuable intervention for cancer patients to improve mood, sleep quality and reductions in stress. ³⁹

These results, however, need to be interpreted with caution. In terms of how to enhance psycho‐spiritual well‐being, half of the reviewed primary studies focus on American patients (mainly Caucasians), and further studies are needed to investigate these issues in a more diverse population. ³⁴ High‐quality trials with a larger sample size and a longer follow‐up are needed to support the effectiveness of interventions on patients’ psychological well‐being. ⁹ , ³¹ , ³² , ³³ , ³⁵ , ³⁶ Evidence of positive effects of relaxation training on cancer patients is also limited because of the poor methodological quality of each primary study, such as use of convenience samples of cancer outpatients (mostly in the early stages of breast cancer), ³⁸ a relatively small sample size, and self‐reported outcome measures for mood, stress, anxiety, and QOL. ³⁹

The evidence for hypnotherapy in the management of symptoms (e.g., pain, anxiety, and depression) in terminally ill adult cancer patients was evaluated in a systematic review, which highlighted the paucity of robust clinical trials to support its use. ⁴⁰ Two review papers on music therapy in cancer patients reported that music therapy has a positive effect on anxiety and mood, but because of the lack of randomization with large sample sizes, the results were not generalizable. ⁴¹ , ⁴² In a Cochrane review, massage and aromatherapy massage have been found to provide short‐term benefits on psychological well‐being in patients with cancer; however, evidence was limited because of variations in style of intervention between studies. ⁴³

Despite a significant volume of research in this area, there is insufficient evidence to show whether interventions help patients improve their mental attitudes. More methodologically sound research is needed.

Sub‐theme 5: impact of aftercare on patients (three review papers identified)

Providing cancer‐relevant information to cancer patients improves their ability to cope during the diagnosis, treatment and post‐treatment phases. ⁴⁴ Rutten et al. ⁴⁴ conducted a systematic review to summarize cancer patients’ information needs and the sources from which they receive information, and identified that patients want to receive treatment related information, that health professionals are the most frequent source of information and that patients’ information needs change along the continuum of cancer care. A Cochrane review of studies on the QOL of patients with lung cancer showed that some interventions (e.g. nursing interventions to manage breathlessness, nurse follow‐up, counselling) might be effective, ⁴⁵ although the evidence was not conclusive. Both reviews, however, pointed out methodological limitations with primary studies. In terms of patients’ information needs, only a minority of primary studies employed previously validated instruments, and very few utilized longitudinal study designs, which made it difficult to assess how patients’ needs and information sources may change over time. ⁴⁴ Many of the interventions tested on lung cancer patients in the trials had a number of different components, any one or combination of which may or may not have produced a positive or negative effect. ⁴⁵

Collins et al. ⁴⁶ conducted a structured review of primary research on the effectiveness of follow‐up services for breast cancer patients and found that there is little evidence to indicate what practices are effective in meeting the objectives of follow‐up services for patients treated for breast cancer. Specific service issues, such as how long follow‐up should last, the frequency of appointments and/or which health professional should deliver the service, were also remain unclear. ⁴⁶

Our systematic appraisal revealed that evidence is limited to demonstrate whether aftercare services meet the needs of cancer patients and how they impact on the lives of patients.

Sub‐theme 6: impact of cancer on patients’ social functioning (two review papers identified)

A literature review on psychological and social sequelae of secondary lymphoedema (a possible side‐effect of breast cancer treatment) (SLE) reported that numbers of women with SLE experience negative impacts on their everyday lives; however, the primary studies reviewed had methodological problems. ⁴⁷ Regarding social aspects of patients’ lives, primary papers in this review indicated that some women avoided socializing as a consequence of their lymphoedema, resulting in social isolation, and many had to give up or cut down on activities, such as crocheting, tennis, golf, gardening, and walking partly because of the social discomfort of the lymphoedematous arm. ⁴⁷ A literature review on fatigue in cancer patients during and after treatment reported that the reviewed studies clearly indicated that fatigue was a problem for many cancer patients undergoing treatment. ⁴⁸ Some primary studies in this review found fatigue to be associated with decreased daytime activity amongst many cancer patients. ⁴⁸

No systematic review was available for this area; however, the literature review papers we identified indicate that some cancer symptoms affect patients’ social functioning. There is no clear advice for how patients can manage the problem in everyday life.

Sub‐theme 7: impact of pain on quality of life (one review paper identified)

Zaza and Baine ⁴⁹ critically reviewed the evidence for an association between chronic cancer pain and psychological distress, social support and coping, and reported significant associations between increased pain and increased distress, and moderate associations between increased pain and decreased levels of social activities and social support. In terms of an association between cancer pain and various coping styles, the evidence was inconclusive.

The quality of many primary studies in the review was limited by some problems; details of study methods were unclear or lacking (e.g., sample size calculation, sample size justification or power calculations, definition of the primary outcomes); and there were omissions in the details of study results (e.g., response rates, reporting raw data, reporting statistics used to support summary statements of significance). ⁴⁹

It is difficult to summarize research in this area using only one review paper; however, the critical review paper we identified suggested that more research is needed on the associations between chronic cancer pain and social support and coping. ⁴⁹

Sub‐theme 8: role of diet in managing cancer (four review papers identified)

Two literature review papers on the outcome of lifestyle changes in cancer patients included a change of diet as a lifestyle change. These reviews reported that despite a large amount of research in this area, no clear association has been found between diet and cancer recurrence or patients’ survival. ⁵⁰ , ⁵¹ The evidence for the benefits of soy isoflavones for breast cancer survivors is also inconclusive owing to the paucity of scientific data on this population, although this review was less structured with an unclear literature search and review process. ⁵² The relation between weight loss and disease outcome was discussed in a literature review, which found that in patients with cancer weight loss is a common problem which affects a patient’s response to treatment, as well as survival and QOL. ⁵³ Early identification and assessment of cancer‐related weight loss through nutritional screening is therefore crucial. ⁵³

No systematic reviews were identified for this theme; however, the review articles identified did not show clear association between diet and cancer recurrence or patients’ survival. Most dietary information that can be provided at the moment, therefore, seems to be focused on the avoidance of malnutrition.

Sub‐theme 9: effect of living with a partner or a family on recovery (two review papers identified)

Ballantyne ⁵⁴ identified that being married was protective in terms of outcomes for breast cancer, although a maladjusted or non‐supportive spouse may harm patient’s well‐being and disease outcomes. These findings, however, should be treated with caution because the literature review process and the design of each study (e.g., whether it was a randomized controlled trial or not) were unknown. A systematic review on QOL amongst long‐term breast cancer survivors has drawn inconclusive evidence for the association between marital status and QOL of long‐term breast cancer survivors. ⁵⁵

Although the evidence for this research area appeared to be inconclusive, the review articles included here concentrated on breast cancer patients only. Research on patients with other types of cancer is also essential.

Sub‐theme 10: relationship between lifestyle and survival (10 review papers identified)

Kuhn et al. ⁵⁰ reviewed literature on behavioural changes, including smoking, alcohol consumption, the use of sun screens and exercise, and reported that former smokers have a significantly lower risk of cancer than current smokers and that patients are less likely to experience a recurrence of cancer if they stop smoking. ⁵⁰ The effect of cessation of alcohol and the use of sun screens on cancer recurrence and survival time remains unclear. In terms of exercise, they concluded that the evidence for the beneficial effect of exercise on cancer survivors is still patchy. ⁵⁰ In another literature review on lifestyle changes, including exercise in cancer patients, studies reviewed showed that exercise was clearly associated with many benefits for the cancer survivor, but the impact of exercise on survival remains to be determined. ⁵¹

The other eight papers reviewed effects of exercise on cancer patients exclusively. Of all, four papers were systematic reviews, ⁵⁶ , ⁵⁷ , ⁵⁸ , ⁵⁹ which led to the following conclusions: exercise appears to be a safe, feasible intervention that can have a positive effect in ameliorating many symptoms associated with cancer and its treatment; ⁵⁶ exercise was found to improve QOL, caradiorespiratory fitness, physical functioning, and symptoms of fatigue amongst breast cancer patients. ⁵⁷ There was a positive effect of exercise on cancer survivors in improving cardiorespiratory fitness during and after cancer treatment, and vigour post‐treatment; ⁵⁸ physical functioning was found to increase amongst patients who exercised, although there was no evidence to determine the effect of exercise on long term outcomes relating to cancer recurrence or survival; ⁵⁹ a Cochrane review on the effect of exercise on breast cancer patients also concluded that exercise during adjuvant treatment can improve physical fitness and thus the capacity for performing activities of daily life; however, this review reported that an improvement for other outcome variables (i.e., fatigue, weight, QOL, depression, strength, immune function or mood) was still tenable, because of a lack of evidence. ⁶⁰ Two literature reviews revealed that physical exercise has promising effects on both physiological and psychological outcomes of cancer patients during and after treatment. ⁶¹ , ⁶²

Physical exercise and immune system function in cancer survivors were examined in a comprehensive review, which suggested that physical exercise training may improve a number of immune system parameters that may be important in cancer defence. ⁶³

There have been a large number of studies on the effectiveness of lifestyle factors in cancer patients, and the effectiveness of exercise has particularly attracted researchers’ attention. Our systematic appraisal demonstrates a positive effect of exercise on cancer survivors; however, each review paper noted some limitations within each primary study that need to be considered. Moreover, the evidence on the impact of exercise on long‐term disease outcomes still remains to be determined.

Discussion

This systematic appraisal identified a number of research areas, identified by cancer patients participating in the Macmillan Listening Study, which have not been adequately explored, indicating that these areas are potentially fruitful areas for further academic enquiry. This study also revealed that some areas within the sub‐themes have already been explored, which suggests that the findings of research could be disseminated more efficiently to a wider audience including service users. This has been recognized in other, ⁶⁴ , ⁶⁵ , ⁶⁶ but it is evident that the need for better dissemination of research findings remains. This appraisal also found that some areas within each of the sub‐themes had been researched before; however, their significance was limited by the scope or quality of the research. This suggests that further research is needed to enhance the generalizability and/or significance of findings. The research areas that are currently under‐researched and that have already been explored are summarized in Table 3.

Table 3.

 Summary of the research areas that are currently under‐researched and that have already been explored

	Sub‐themes	Under‐researched areas	Current research evidence
1	Psychological impact of cancer from point of diagnosis	How patients can cope with psychological and emotional problems in everyday life still needs to be studied.	Patients living with cancer experience various psychological and emotional problems.
2	Impact of cancer on family and friends	More research is needed on how to support family members of cancer patients. The impact of cancer on friends of cancer patients is unknown.	Cancer has an impact on family members of cancer patients.
3	Impact of positive mental attitudes or stress on recovery and survival	There is no clear evidence to support the association between positive mental attitudes and recovery and survival, despite numerous studies being conducted in this area.
4	How to improve mental attitudes	Despite a significant volume of research in this area, there is insufficient evidence to show whether interventions help patients improve their mental attitudes. Further research needs to be conducted for more conclusive evidence in this area.
5	Impact of aftercare on patients	More research is needed to demonstrate whether aftercare services meet the needs of cancer patients and how they impact on the lives of patients.	There is some research on how aftercare services may operate.
6	Impact of cancer on patients’ social functioning.	Further research is needed on how patients can manage the problem (e.g., social isolation) in everyday life.	Some cancer symptoms affect patients’ social functioning.
7	Impact of pain on quality of life	More research is needed for more conclusive evidence for an association between cancer pain and various coping styles.	Increased pain is associated with increased distress, lower social support and engagement in fewer social activities.
8	Role of diet in managing cancer	There is no clear association between diet and cancer recurrence or patients’ survival.	Weight loss is a common problem in patients with cancer.
9	Effect of living with a partner or family on cancer recovery	The evidence for this research area appeared to be inconclusive. Research on patients with cancer other than breast cancer is essential.
10	Relationship between lifestyle and survival	There is no conclusive evidence for the effect of exercise on cancer recurrence and survival. The effect of other lifestyle factors (the cessation of alcohol and the use of sun screens on cancer recurrence) on cancer recurrence and survival time also remains unclear.	Former smokers have a significantly lower risk of cancer than subjects who still smoke. Patients are less likely to experience a recurrence of cancer if they stop smoking. Exercise may have short‐term benefits for cancer patients and survivors.

An effective approach of ensuring that the focus, conduct and dissemination strategies of research reflect the needs of people affected by cancer is to involve patients and others throughout the research process. ⁶⁷ People affected by cancer can contribute effectively to discussions and decisions about appropriate avenues for future research. ¹

All the sub‐themes explored in this study are important issues related to cancer survivorship, which have been recently recognized as an emergent field of research. ⁶⁸ Research into issues surrounding cancer survivorship should be stimulated and supported as this will provide fruitful insights into policy and governmental actions that may be taken to provide a supportive infrastructure for cancer survivors. ⁶⁷ The under‐explored areas identified in this study will help provide research areas to be explored to improve services for cancer survivors.

Limitations

The systematic appraisal had several limitations. The findings from the systematic appraisal were based on published literature reviews. It is therefore possible that important and relevant findings from key primary data papers were omitted as they were not included in a literature review. Grey literature was also excluded. The quality of each literature review paper was not assessed. Formal processes for establishing rigour, such as the independent extraction of findings of each review paper, were not employed, resulting in a greater risk of subjective bias. Finally, focusing exclusively on published review papers can generate a bias towards certain types of research. This is attributed to a tendency for systematic literature reviews to use a hierarchy of evidence that rates findings from randomized control trials more highly than qualitative studies. Similarly, the criteria for appraising the quality of quantitative studies are well developed while those for qualitative studies are less so. ⁶⁹ Consequently, there is a tendency for qualitative studies to be poorly represented in literature reviews, which results in an over‐representation of quantitative studies in this systematic appraisal.

Regarding the literature review process, employing a more flexible approach, such as realist review, ⁷⁰ can be considered in future. Realist review principles can be helpful to conduct a study of this kind, as it is designed for synthesizing research which has an explanatory rather than judgemental focus as seen in systematic review.

Conclusion

This systematic appraisal of literature reviews has enabled greater understanding of the top priority area for research identified by participants in the Macmillan Listening Study. This has provided a starting point for the development of research projects from the top priority area. A more detailed literature review on each of the sub‐themes will be beneficial before using the findings from this study to inform research activity in future. This systematic appraisal adopted and utilized an effective means of appraising literature relating to a broad range of research interests. We recommend that similar systematic appraisals are undertaken not only for the remaining priority areas from the Listening Study, but also for other research topics that include a wide range of research areas.

Conflict of interest

There is no conflict of interest regarding this study.