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Nontraditional and Home-Based Self-management Interventions in Cancer Patients With Pain

A Mixed-Method Systematic Review

You, Eunhea PhD, RN, MSN

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doi: 10.1097/HNP.0000000000000380
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Abstract

INTRODUCTION

It is estimated that there were more than 15.5 million US cancer patients in 2016.1 This number will continue to grow to approximately 23 million by 2026 due to early diagnosis and medical and technology advancement.1 From 30% to 85% of cancer patients experience pain; 66% of advanced cancer patients, 55% of cancer patients undergoing cancer treatment, and 30% of cancer patients who have completed cancer treatments.2 Approximately 50% of cancer patients who experience pain develop chronic pain even though they received traditional (mainstay of) pain therapies.3 As a result, many cancer patients are no longer satisfied with traditional pain managements.4 Thus, they look for nontraditional interventions to manage their pain.5

One or 2 decades ago, oncologists focused on only cancer treatments or acute care related to cancer.14 This old practice has been changed now that cancer care should be considered continuing or long-term care. Furthermore, cancer treatment and end-of-life care is increasingly shifted to the outpatient or home settings. These patients deal with pain on a daily basis at home. It is crucial that cancer patients should be equipped with many self-management (SM) skills to control their pain.

The concept of SM and SM support is developed from Alberta Bandura's self-efficacy.6 Self-management is defined as the combined knowledge, ability, and confidence of patients with any chronic disease or condition who manage their symptoms, treatments, and lifestyle changes in daily life.7 When patients feel confident in their ability to control their health, they tend to have greater success in attaining their health goals. If multidisciplinary teams support and/or implement SM interventions for patients, these patients can improve their chances of successfully managing their disease and its symptoms.8 Evidence suggests that health education alone is an insufficient form of SM support. By itself, health education is not keeping patients engaged in health-promoting behaviors.9–12 However, SM support can be valuable in health-related goal setting, self-assessment, action planning, problem-solving, or follow-up. In order to have successful SM support, multidisciplinary teams and patients should actively communicate. Additionally, everyone in the team, including patients, must understand that the patients are in charge of their long-term care. Multidisciplinary teams and patients are partners in achieving these patients' health goals.

Only few nontraditional and home-based SM intervention studies have been conducted based on non-SM theories such as rational-emotive behavior theory.15 Self-management and Self-management intervention application in the chronic care model (CCM) is practically incorporated and has been studied in many different patients with chronic diseases such as diabetes,16,17 asthma,7,18 cardiovascular disease,7 and depression.19 However, few studies were conducted for cancer patients.20 When a multidisciplinary health care team proposes to provide SM support, the team may employ the 5A approach (offering Assessment, Advice, Agreement, Assistance, and Arrangement).13

This review evaluates quantitative and qualitative studies to compare the effect of nontraditional SM interventions for cancer pain conducted at home. Among nontraditional SM interventions for cancer pain, education alone is less effective than other nontraditional SM interventions. This review also explores the application of SM support in the CCM as a future guidance for SM intervention studies and practices since few studies included in this mixed-method systematic review were framed with an SM theory. Thus, the results can not only inform health care providers and researchers how to empower cancer patients in a collaborative way, but also guide health care policy makers seeking to enhance patients' outcomes.

METHODS

This mixed-method systematic review was updating previous studies by Hammer et al,22 Koller et al,23 and McCorkle et al.21 Koller et al23 conducted the review of solely SM educational interventions on cancer pain. McCorkle et al21 and Hammer et al22 conducted a review of studies on broad symptoms of cancer patients, including nausea, pain, and vomiting.

PubMed, CINAHL (EBSCO), Scopus (Elsevier), and Cochrane Central Register of Controlled Trials (Wiley) were used to search the literature for the period from January 2011 to May 2018. The search terms used were “self-management,” “self-care,” “pain self-management,” “self-management interventions,” “non-traditional self-management interventions,” “home-based self-management interventions,” “cancer,” “oncology,” “pain,” “cancer pain,” and “cancer pain symptom.”

Inclusion and exclusion criteria

All selected studies included nontraditional SM interventions targeting cancer patients living with pain. These studies featured SM interventions that were incorporated into home-based activities. Educational, exercise, or complementary and alternative medicine (CAM) therapy interventions can be used as a nontraditional and home-based SM intervention. However, if those interventions required an interventionist without the self-administrating part during the entire intervention, those interventions are no longer a home-based SM intervention. For instance, yoga can be a non-traditional and home-based SM intervention. However, if yoga requires an instructor during the entire intervention, the yoga intervention is no longer a home-based SM intervention in the specific situation. All literatures were published in peer-reviewed journals, written in English, and measured pain outcomes using either quantitative or qualitative methods. Self-management interventions that were not conducted at cancer patients' homes, that measured the effects of traditional interventions such as pharmacology therapies and surgical and medical procedures, or that had no pain outcomes were excluded.

RESULTS

The author located 510 articles (507 quantitative, 3 qualitative). After correcting for duplication, 395 articles remained (392 quantitative, 3 qualitative). The author screened only titles and abstracts and excluded 327 articles that did not meet inclusion criteria. Another 49 quantitative articles and 1 qualitative article were eliminated after reviewing the full text for the following reasons: they were not home-based SM studies (n = 38), no pain outcomes were reported (n = 7), and the interventions were conducted on health care providers, not on cancer patients (n = 5).

A total of 16 quantitative and 2 qualitative nontraditional and home-based SM intervention studies were included in this mixed-method systematic review (Figure). All interventions are divided into 3 types: use of an educational and/or counseling program, use of CAM therapy, and use of exercise (Tables 1 and 2). All interventions required that participants receive a minimum amount of instruction and assessment to explain a specific program or intervention.

FIGURE.
FIGURE.:
Flowchart of the publication selection process.43
TABLE 1. - Nontraditional/Home-Based Self-management Interventions in Quantitative Studies
Study/Country Self-management Intervention/Duration Sample/Cancer Phase Self-management Support Conclusion
Educational and/or counseling programs
Koller et al27/
Germany
ANtiPain intervention (PRO-SELF plus PCP was adapted by the local German context) for 6 wk. ANtiPain intervention consists of information, skill building, and nurse coaching 39 adult oncology patients/mix phase of treatment and end of life Face-to-face and telephone calls biweekly for pain education and self-management strategies. Taught how to manage pill box ANtiPain intervention had large effects on activity hindrance, barriers, and self-efficacy and had small-to-moderate effects on average and worst pain. However, the results were not conclusive since 37% of patients declined participation
Ohlsson-Nevo et al31/Sweden Psychoeducational program (PEP) over 7 wk. Once a week 60-min lecture of cancer progress, treatment options, and fear management. Plus, a social worker counseled the participant for social needs whenever needed 86 colorectal cancer patients/survivorship Encouraging self-pain management as sharing their experience with the research team members PEP had a positive effect on bodily pain only on 6 mo of PEP intervention (P < .01) (not before or after 6 mo of PEP)
Risendal et al32/USA CDSMP for 6 sessions of workshop (each workshop lasted 2.5 h). The pain instruction was tailored to the need and the ability of the individual patient 214 cancer patients (tumor, breast, urogenital)/survivorship Education of SM skills, sharing experience, goal setting, plan feedback, problem-solving, and decision-making Pain in CDSMP group was lower, but not statistically significant than control group (P < .2)
Rustøen et al29/Norway PRO-SELF PCP for 6 wk at home (5 home visits and 6 phone calls by a nurse) 179 cancer patients with bone metastasis/mix phase of treatment and end of life Education of pain self-monitoring and effective communication of pain control with participants physicians No group difference between PRO-SELF PCP group and control group in the total dose around-the-clock dose, or as-needed dose of opioid analgesics taken
Koller et al30/
Switzerland
PRO-SELF PCP for 10-wk (6 visits and 4 phone follow-up calls by intervention nurses) 39 cancer patients (lung, breast)/survivorship Setting up a mutual agreement on pain self-management's strategies between intervention nurses and participants The intervention group showed a significant increase in knowledge, but pain severity and self-efficacy
Kim et al24/South Korea Written booklet and video-aided presentation for pain management and NP coaching and monitoring of pain (30 min) for 1 wk and 2-mo follow-up 108 advanced cancer patients (GI tract, lung)/end of life NP coaching based on participants' or their families' questions for pain management The intervention group showed more significant improvement in pain than the standard group (P = .02)
Mahigir et al15/Iran REBT (stress management) over 8 sessions (each session lasted 2 h) 88 cancer patients/survivorship Counseling and education of daily stress management No difference in sensory and affective pain scores between REBT and control groups
Thomas et al28/USA 3 groups: coaching, education, and control. The coaching and education groups watching a video and received a pamphlet on managing cancer pain. The coaching group added 4 (1 time for 30 min) telephone calls of pain management strategies by an ANP 318 cancer patients (lung, head and neck, prostate)/survivorship Encouraging coaching and education groups to use pain management according to their preference Coaching group for cancer pain management exhibited a significantly greater effect than other 2 groups (P = .01)
Kwekkeboom et al33/USA PCCB: Imagery, relaxation exercises, and natural sounds were implemented through an MP3 player for 2 wk whenever participants decided to use them for their pain. One session lasted 20 min 86 cancer patients (gynecologic, prostate) receiving chemotherapy, radiation therapy, and chemo + radiation/survivorship Education of how to use PCCB strategies Participants in the PCCB intervention reported less pain severity at the end of intervention than did persons in the waitlist control group (P =.05)
Kravitz et al12/USA TEC: Correcting pain misconception, identifying a pain goal, training new pain control skills, and reinforcement of the new skill training over 6 mo. Total hours of TEC training were 30-40 258 cancer patients who completed chemotherapy and radiotherapy within 2 wk/survivorship Training for self-pain assessment and effective communication between patients and physicians for pain management TEC improved pain communication, but no improvement in pain severity
Oldenmenger et al26/
Netherlands
PEP/PC: Instruction of knowledge of pain and stimulating help-seeking based on national cancer pain guidelines and telephone calls by a nurse over 8 wk 59 cancer patients/end of life Encouraging patients' help-seeking behavior Reduction in pain intensity and daily interference was significantly greater after intervention to PEP-PC than to standard care (P = .01)
Borneman et al25/USA Educational and/or counseling program/4 education sessions of pain management, nutrition, sleep disturbance, emotional issues, and exercise and 6 follow-up calls by an ANP for 3 mo; 1 session lasted 60 min 280 cancer patients (breast, lung, colon)/end of life Education of self-exercise, emotional control, and pain self-assessment There were significant immediate effects in reducing participant barriers to pain management (P = .001).
Complementary and alternative medicine therapy
Yeh et al2/USA AA for 4 wk: An acupressure therapy that is used on the ear. AA uses stimulators (seeds), which are covered by a small piece of waterproof tape pressure by fingers. Intervention study with wait-list control group. Self-pressing techniques on 3 acupoints by participants (3 times a day and 3 min on each acupoint) 20 breast cancer patients receiving aromatase inhibitor therapy/cancer treatment Self-assessment of pain. Daily diary to write pain symptoms and AA self-administration The AA group significantly decreased in worst pain (50%), pain interference (42%), and improvement of physical function (31%) as increasing anti-inflammatory cytokines (30%) and decreasing pro-inflammatory cytokines (30%) compared to the control group
Yeh et al36/USA AA for 4 wk. Self-pressing techniques on 8-12 ear acupoints by participants (3 times a day and 3 min on each acupoint) 31 breast cancer patients were off cancer treatments and in survival stage Self-report of pain symptoms AA had reported a significant reduction of 71% in pain, 44% in fatigue, 31% in sleep disturbance, and 61% in interference with daily activities
Yeh et al2/USA AA for 7 d. Self-pressing techniques on 5-9 ear acupoints by participants (at least 3 times a day and at least 3 min on each acupoint) 55 adult cancer patients (36 active treatments and 14 cancer survivors) from a university hospital clinic Self-report of pain symptoms AA significantly reduced pain intensity more than 55% for worst pain, 57% for average pain when the participants applied AA
Exercise
Cantarero-Villanueva et al38/Spain Internet-based exercise intervention based on recommendation of the American College of Sports was implemented for 8 wk, 3 sessions per week. One session (90 min) was composed of warm-up, resistance and aerobic exercise training, and cool-down 81 women with breast cancer/survivorship Using an online system to facilitate a remote and tailored exercise program at patient's home The intervention group reported significantly lower pain severity (P = .001) and pain interference (P = .045)
Abbreviations: AA, auricular acupressure; APN, advanced practice nurse; CAM, complementary and alternative medicine; CDSMP, chronic disease self-management program; GI, gastrointestinal; NP, nurse practitioner; PCCB, patient-controlled cognitive-behavioral; PCP, pain control program; PEP/PC, pain education program/pain consultation; RCT, randomized controlled trial; REBT, rational-emotive behavior therapy; SM, self-management; TEC, tailored pain management education and coaching.

TABLE 2. - Nontraditional/Home-Based Self-management Interventions in Qualitative Studies
Study/Country Self-management Intervention/Duration Sample/Cancer Phase Self-management Support Conclusion
Educational and/or counseling intervention
Schumacher et al40/USA PRO-SELF PCP was performed for pain medication management for 10 wk at home 42 cancer patients and 20 family caregivers via a mix-method design/
survivorship
Education of self-administration of pain medication Patient- and family-centered SM skill training was needed to achieve effective and safe pain medication management in the context of individual home environments
Hodge et al39/USA Utilizing video-taped education tool (titled “Weaving Balance into Life”). Information of cancer, illness beliefs, communication styles, barriers, and recommendations for pain self-management 132 Indian cancer patients, family, and others (caregivers, community leaders, and friends)/survivorship Encouraging a motivational pain self-management and to use a cancer resource directory Pain management of American Indian survivors was needed to tailor and combine with their culture and belief
Abbreviations: PCP, Pain control program; SM, Self-management.

Quantitative nontraditional/home-based self-management intervention studies

The 16 quantitative studies utilized educational and/or counseling programs (n = 12), CAM therapy (n = 3), and exercise (n = 1). The 9 countries in which the research was conducted are shown in Table 1. The mean age of participants in these studies ranged from 48 to 66 years. A total of 1753 participants took part in the educational and/or counseling program studies, 106 took part in the auricular acupressure (AA)/CAM studies, and 81 took part in the exercise study. More women than men took part in these 16 studies; 62.2% were women, while 37.8% were male. Seven studies that included white subjects made up the majority of study participants, ranging from 62% to 93% of the total sample, but 9 studies did not report participant ethnicity. Most studies recruited participants diagnosed with more than one type of cancer: breast cancer (n = 8), lung cancer (n = 4), other (n = 3), gastrointestinal cancer (n = 2), urogenital cancer (n = 2), head and neck cancer (n = 1), and lymphoma (n = 1). Only 4 studies reported the cancer stage of study participants. Five studies of the 16 did not report the proportion of participants who dropped out while 7 studies had less than a 20% dropout rate (4 studies had more than a 20% dropout rate). Six studies included patient family members in the intervention process. On a scale of 0 to 10 points, most studies (n = 10) included only those who reported that their pain was at a level of 3 to 4 or above. These pain outcomes included pain severity, physical function, pain self-efficacy, pain blood biomarkers, and pain medication usage. To collect data regarding cancer pain across all 16 studies, 14 instruments were used: Brief Pain Inventory (n = 7), Pain Self-Efficacy Scale (n = 5), Short Form Health Survey (n = 3), Numeric Rating Scale (n = 3), Karnofsky Performance Scale (n = 2), Patient Pain Questionnaire (n = 1), MD Anderson Symptom Inventory (n = 1), Pain Management Index (n = 1), Visual Analogue Scale (n = 1), McGill Pain Questionnaire (n = 1), Functional Status Scale (n = 1), oral morphine-equivalent calculation (n = 1), and Medication Quantification Score Version Ш (n = 1). More than 80% of these studies used 2 or more pain outcome measurements. All studies used subjective measures and some studies also utilized objective measures (n = 3) or biomarkers (n = 1).

The quantitative SM interventions across these 16 studies were employed more often during the survivorship phase (n = 9) than during the treatment phase or at the end of life. All the CAM and exercise intervention studies only appeared during the last 3 years of the review period, and the CAM studies used only AA interventions. However, the number of educational and/or counseling intervention studies has decreased since 2013 in this review, and only the educational and/or counseling program studies were guided by a theory.

Educational and/or counseling programs

Across the 12 quantitative intervention studies, 10 held educational and counseling sessions and 2 held only educational sessions. There was variability among the educational and/or counseling programs presented with differences in type and duration of intervention, and study design: different types of comparison group. Educational and/or counseling programs included psychoeducational programs (PEPs), PRO-SELF pain control programs (PRO-SELF PCPs), cognitive-behavioral (CB) programs, rational-emotional therapy programs, and problem-solving training programs.

Telephone counseling was usually used at the end of life in cancer patients because the cancer patients could not go to see their doctor due to physical limitations.24–27 The pain outcomes of these studies were mixed. Three studies using PRO-SELF PCP as the chosen home-based SM intervention did not report statistically significant results.24–26,28 The key strategies used in PRO-SELF PCP were pain management knowledge provision, skill building, and nursing coaching. All 3 PRO-SELF PCPs utilized slightly different strategies based on the host countries and populations targeted. All 3 PRO-SELF PCP studies found that, while knowledge improved, the intervention did not change patients' behaviors regarding pain management. Ohlsson-Nevo et al31 and Oldenmenger et al26 tested the effect of a PEP on cancer pain management, and the 2 studies reported statistically significance on pain severity. Oldenmenger et al26's PEP stimulated patients' help-seeking behavior based on World Health Organization (WHO) pain guidelines. Ohlsson-Nevo et al31's PEP educated participants regarding general pain management and relaxation techniques. Risendal et al32 tested the effect of a chronic disease SM program (CDSMP) on cancer patients with pain. The CDSMP utilized education intervention aimed at building skills, sharing experiences, and generating support among the participants. The authors reported that pain outcomes were not statistically significant. Kwekkeboom et al33 used an education-based intervention utilizing 12 CB techniques to relieve not only cancer pain but also fatigue and sleep. The 12 CB techniques were divided into 4 categories: symptom-focused imagery, natural focused imagery, relaxation exercises, and nature sounds. Participants could choose 1 of 12 CB strategies depending on their preferences for 2 weeks. Behavior pain outcomes were statistically significant (P = .05).

Complementary and alternative medicine therapy/auricular acupressure

Complementary or alternative medicine (CAM) therapies have been utilized to assist cancer patients who were not satisfied with western approaches to pain management. Guidelines and recommendations for CAM have been supported by the National Comprehensive Cancer Network guidelines, the WHO, and the National Institutes of Health. There are 7 types of complementary or alternative medicine modality for pain management in the United States (acupuncture, acupressure, massage, yoga, hypnosis, relaxation/progressive muscle relaxation, and guided imagery, biofeedback). Not all CAM therapies can be incorporated into an SM component. For instance, acupuncture therapy requires an acupuncturist or specialist during the entire intervention. However, AA therapy only requires an acupuncturist or specialist at the beginning of an intervention, because the patient can self-administer the rest of the intervention.34

All the 3 CAM SM intervention studies in this review used only AA therapy during cancer treatment or survivorship (Table 1). Auricular acupressure uses stimulators (referred to as “seeds”) taped onto the ears.35 Theses stimulators are made of botanical, metal, or magnetic materials: they are used in place of the needles utilized in standard acupuncture.2 The 3 studies showed that AA was statistically effective in relieving cancer pain.2,36,37 However, uncertainty remains regarding the strength of the evidence, due to the small number of studies included and the lack of consistent methodologies employed.

Exercise

Exercise has been used to relieve symptoms such as pain and fatigue and enhance physical function, anxiety, depression, and quality of life on cancer patients. Cantarero-Villanueva et al38 tested the effects of 3 parts of exercise (warm-up, resistance and aerobic exercise training, and cool-down sessions) on cancer survivors living with pain: the intervention was offered 3 times per week and each session was offered online and lasted 90 minutes. The authors reported significant interaction effects for pain severity and pain interference.

Qualitative nontraditional/home-based self-management intervention studies

Two qualitative studies were included in this review (Table 2). The studies incorporated only educational and/or counseling programs (n = 2). Both were based on grounded theory methodology.

Educational and/or counseling programs

All qualitative home-based SM intervention studies (n = 2) utilized a combination of education and counseling sessions. The 2 interventions employed in these qualitative studies utilized PRO-SELF PCP and an educational toolkit (including a motivational video, a cancer symptom SM guide, and a cancer resource directory). Hodge et al39 developed a pain management toolkit specifically for South American Indians. The author reported that cultural considerations such as language differences, illness beliefs, cultural practices, and literacy levels must be incorporated into cancer pain SM. Schumacher et al40 utilized a mix-methods approach. The authors explained that pain medication processes should consider individual contexts, including ways of understanding, organizing, storing, scheduling, remembering, and taking the medications at home.

Application of self-management support (5A)

The application of SM support was adopted for an intervention by the behavior change model. The behavior change model proposes that an intervention should be orderly, conducted using ongoing assessment, advice, agreement, assistance, and arrangement (the 5A approach) in the primary care setting. The main focus in application of SM support is the personal action plan. The personal action plan is for patients to make their own health goals and follow-up plans.

Assessment

Recent evidence has proven that if health care providers assess patients' SM skills, confidence, knowledge, supports, belief, barriers, and risk factors to maintain their health, health care providers can provide feedback to their patients and their interdisciplinary team based on their patients' SM, so the teams and patients can enact better care plans for patients' chronic illnesses.41 There are useful tools to assess patients for SM. General patient information, treatment information, pain information, perceived treatment efficacy, and performance status can be used in part or in totality for the initial and ongoing assessment of SM by an interdisciplinary team.

Advice

Advice can be given by the disciplinary team or by other patients who have similar diseases or symptoms, but the advice should be based on current evidence and knowledge.41 Through shared advice, patients can make or revise their health goals and plans. The team can discuss the benefits of SM and explain the application of SM interventions.

Agreement

Agreement can occur any time after the assessment of patients. Patients and multidisciplinary teams may collaboratively finalize health goals and plans and select treatment based on the patient's preference, ability, and confidence, in order to improve their chronic symptoms and conditions.41 The goals and plans are not abstract, but they should be small and behavior-specific. The goals should include measures that can be reached within 3 to 6 months.41

Assistance

Assistance can occur any time after the assessment of patients. A health care disciplinary team should help patients to achieve their goals and plans by providing education, encourage patients, and connecting peers who have the same health problems.41 Open communication between the team and patients, and within the team itself, is crucial.

Arrangement

Arrangement of resources to improve one's health can occur any time after the assessment of the patient. A multidisciplinary team can schedule follow-ups or referrals to specialists to continue support for patients and improve patients' SM.41

DISCUSSION

This mixed-method systematic review evaluated 16 quantitative and 2 qualitative studies utilizing nontraditional and home-based SM interventions for cancer pain. Pain outcomes included in these studies were pain severity, physical function, pain self-efficacy, and pain medication usage. All home-based SM interventions in this review were divided into 3 types: use of educational and/or counseling programs, use of CAM therapy, and use of exercise. The 16 quantitative studies utilized all 3 types of interventions; however, the 2 qualitative studies used only education and/or counseling programs.

Ten of the included 16 quantitative studies reported statistically significant results with regard to pain outcomes such as pain severity and pain medication usage: 3 CAM studies (100%), 1 exercise study (100%), and 6 of the 12 educational and/or counseling studies (50%). Thus, CAM and exercise interventions provide promising avenues for pain management in cancer patients compared with the use of only educational and/or counseling programs. However, little is known about the mechanism by which CAM and exercise work, and we cannot conclude that CAM and exercise therapies are better than educational and/or counseling programs based on the small number of the studies conducted. We need further studies on pain management in cancer patients utilizing CAM, exercise, and educational and/or counseling interventions.

The quantitative SM interventions included in this review were varied in study design, duration, and methodology, so it is hard to compare them to one another. Future research should include the development of standard protocols for the delivery of the SM interventions in order to establish evidence. The qualitative SM studies reviewed here suggest that pain intervention and management should be tailored to individual culture.

Most of the studies (n = 11) used home-based SM interventions during survivorship than during cancer treatment or at the end of life. Cancer patients live longer now and they need SM skills in their daily lives. However, cancer patients receiving cancer treatment or at the end of life depend on the skills and assistances of health care providers. Thus, more nontraditional and home-based SM intervention studies can be conducted during survivorship.

Across the 18 studies, few incorporated theories into their chosen SM intervention. Only one study utilized an intervention based on the CCM; however, the study did not observe statistically significant behavior pain outcomes, possibly because it used only an educational program. The study did not incorporate the application of SM support. If so, it is likely that this would change the pain behaviors of patients. The application of SM support influences patients to engage more in their own care to change pain outcomes.

Incorporating physiological biomarkers for pain into SM interventions may be one way to build scientific evidence about effectiveness of the interventions. Current researchers speculate that physiological biomarkers may change depending on the level of pain experience.2 Only one study has measured blood biomarkers such as inflammatory cytokines as pain changes.2 Pro-inflammatory cytokines can be induced by neuron damage and lead to pain,42 so further investigation into the use of nontraditional and home-based SM interventions to buffer the release or action of pro-inflammatory cytokines is warranted.

There are limitations to this mixed-method systematic review. First, only studies published in English were included. Additionally, the number of CAM therapy and exercise studies was small and the intervention periods of these studies were short, so it was difficult to compare them with educational and/or counseling intervention studies. Lastly, methodological variability made cross-study comparison difficult.

CONCLUSION AND IMPLICATION

This mixed-method systematic review informed future implications of SM interventions for better pain management outcomes in cancer patients. The small number of CAM and exercise studies and the lack of protocols and consistent methodologies across the studies preclude that specific interventions can be the best choice among included SM interventions in the review.

This review may inform further research and clinical practice related to cancer pain. First, more studies using the “5A approach” of SM support in the cancer practice would be “useful,” and additional quantitative and qualitative nontraditional/home-based SM studies will be needed to achieve better understanding of cancer pain care. Second, more home-based SM intervention studies including cancer caregivers are warranted. We need to gather evidence about whether it is more effective to include cancer caregivers in a home-based SM intervention in order to enhance care of cancer pain. Third, more research is needed to measure the long-term effects including physiological biomarkers of nontraditional and home-based SM intervention on cancer patients dealing with pain. Lastly, a study utilizing an online, home-based SM intervention for cancer patients is warranted, because the patients may not be able to keep up with their clinical visits due to disease progression and pain.

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Keywords:

cancer patients; nontraditional and home-based intervention; self-management

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