Effect of cognitive behavioral therapy on cancer-related fatigue and psychological status in ovarian cancer patients: A meta-analysis

Table 1 Inclusion and exclusion criteria

PICOS	Inclusion criteria	Exclusion criteria
Population	Patients diagnosed with ovarian cancer who are undergoing chemotherapy after surgery	Patients with other concomitant diseases
Intervention	Using CBT for treatment, but not limited to specific schools of thought within CBT theory, including the third wave, such as ACT, MBCT, DBT, etc.	In addition to CBT, the experimental group also received other treatments
Comparison	CBT is not used, but specific treatment methods are not restricted	No controlled study
Outcome	Cancer-related fatigue, mental health status (such as anxiety and depression levels), and quality of life of patients; there are no restrictions on the scales used to assess the outcomes	Unreliable or incomplete data
Study design	Randomized controls trails	Case report, conference paper, review article and letter; duplicate literature or duplicate studies

PICOS: Population, intervention, comparison, outcomes and study; CBT: Cognitive behavioral therapy; ACT: Acceptance and commitment therapy; MBCT: Mindfulness-based cognitive therapy; DBT: Dialectical behavior therapy.

Table 2 Characteristics of the six included studies[12-17]

Ref.	Country	Study design	Multi-center	Registered	Record patient time	Ovarian cancer patients	Age (T)	Age (C)	Sample size		Intervention (T)	Intervention (C)	Outcome
									T (n)	C (n)
Frangou et al[12]	United Kingdom	RCT	Yes	Yes	November 2013 to January 2018	Primary or relapsed epithelial OC	58.1 ± 9.46	60.9 ± 10.2	34	33	CBT	Standard care	Depression, QoL
Zhou et al[13]	China	RCT	No	NR	January 2018 to March 2019	Meets the diagnostic criteria for OC	58.64 ± 13.82	60.23 ± 15.78	37	36	CBT + conventional nursing	Conventional nursing	Cancer-related fatigue, depression, anxiety, sleep quality, QoL
Zhang et al[14]	China	RCT	No	NR	November 2014 to November 2015	Ages of 18 and 80 with OC	NR	NR	33	34	CBT + exercise	Usual care	Cancer-related fatigue, depression, sleep quality
Petzel et al[15]	United States	RCT	Yes	Yes	September 2012 to February 2013	Stage III/IV or recurrent (any stage) epithelial OC	59.6 ± 10.0	55.5 ± 8.4	16	12	Website based on CBT	Control website	Distress, depression, anxiety
Moonsammy et al[16]	Canada	RCT	No	NR	March 2011 to July 2011	Newly diagnosed with OC	52.7 ± 12.1	57.8 ± 12.0	3	5	CBT	Surveillance	Cancer-related fatigue, depression, anxiety
Rost et al[17]	United States	RCT	No	NR	NR	Women with stage III or IV OC	56	56	15	16	ACT	Treatment as usual	Distress, depression, anxiety, QoL, acceptance

T: Treatment group; C: Control group; RCT: Randomized controlled trial; NR: Not report; OC: Ovarian cancer; CBT: Cognitive behavioral therapy; ACT: Acceptance and commitment therapy; QoL: Quality of life.

Table 3 Characteristics of cognitive behavioral therapy treatment, n (%)

Ref.	Intervention (T) specific method	Intervention (C) specific method	CBT implementer	Intervention duration/frequency/total times or time	Intervention time point	Assessment time point	Follow-up time after treatment	Lost to follow-up
Frangou et al[12]	CBT (face to face sessions)	Standard care	Doctoral-level clinical/counselling psychologist	90 minutes/NR/3 months	The 6-12 weeks post-chemotherapy	Baseline/after treatment 3, 6, 9, 12, 15, 18, 24 months	24 months	40 (37.4)
Zhou et al[13]	At-home CBT + conventional nursing	Conventional nursing	Nurses	Half an hour/3-4 times per week/NR	In the light of chemotherapy	Baseline/after treatment 1, 2, 3 months	3 months	0 (0)
Zhang et al[14]	Nurse-led home-based exercise + CBT	Nurse-led usual care	CBT-trained nurses	1 hour/once weekly/12 consecutive weeks	Before the sixth chemotherapy treatment	Baseline/immediately after treatment/3 month	3 months	3 (4.3)
Petzel et al[15]	Visit website (social cognitive theory + CBT)	Visit website (usual care materials)	Medical and psychological providers	Unlimited time/2-3 times per week/60 days	Post-operative checkup or planned chemotherapy	Baseline/1 month	1 month	6 (17.1)
Moonsammy et al[16]	CBT (counselling sessions by phone)	Surveillance	CBT-trained nurses	1 hour/once every two weeks/12 weeks	Before completing two cycles of adjuvant chemotherapy	Baseline/immediately after intervention/3 months	3 months	5 (26.3)
Rost et al[17]	ACT (face to face meetings)	Treatment as usual	A PhD-level clinical psychologist	1 hour/4 months/12 occasions	In the chemotherapy treatments	Baseline/at the end of the 4th, 8th, and final (12th) session	End of treatment	16 (34)

T: Treatment group; C: Control group; CBT: Cognitive behavioral therapy; ACT: Acceptance and commitment therapy; NR: Not report; Baseline: Before treatment.

Table 4 Meta-regression analysis of depression and anxiety

Analysis	Depression				Anxiety
	Estimate (SE)	95%CI	P value		Estimate (SE)	95%CI	P value
Patients characteristics
Age	0.02 (0.14)	-0.26 to 0.29	0.8838		-0.06 (0.04)	-0.14 to 0.03	0.1733
China	-0.91 (0.59)	-2.06 to 0.24	0.1229
United States	-0.22 (0.65)	-1.48 to 1.05	0.7388		-1.28 (0.56)	-2.36 to -0.19	0.0217a
United Kingdom	-0.16 (0.67)	-1.46 to 1.15	0.8127		-0.85 (0.59)	-2.01 to 0.31	0.1497
Intervention methods
CBT/exercise	-0.49 (0.43)	-1.33 to 0.34	0.2485
I-CBT	0.98 (0.55)	-0.10 to 2.05	0.0767		0.06 (0.53)	-0.98 to 1.10	0.9092
Traditional-CBT	0.23 (0.41)	-0.57 to 1.02	0.5727		-0.27 (0.40)	-1.06 to 0.51	0.4966
Assessment scales
CES-D	0.68 (0.69)	-0.66 to 2.03	0.3179	STAI-Y	0.88 (0.64)	-0.37 to 2.14	0.1704
HADS	0.98 (0.61)	-0.21 to 2.16	0.1073	HADS	0.06 (0.53)	-0.98 to 1.10	0.9092
PHQ-9	0.53 (0.53)	-0.50 to 1.56	0.3157	SAS	-0.40 (0.40)	-1.19 to 0.40	0.3266
SDS	-0.22 (0.45)	-1.10 to 0.66	0.6292
Nurse-led	-0.56 (0.28)	-1.12 to -0.00	0.0486a		1.15 (0.55)	0.08 to 2.22	0.0359a

^aP < 0.05.

CI: Confidence interval; CBT: Cognitive behavioral therapy; I-CBT: Internet-based cognitive behavioral therapy; CES-D: Center for epidemiologic studies-depression scales; HADS: Hospital anxiety-depression scale; PHQ-9: Patient health questionnaire-9; SDS: Self-rating depression scale; STAI-Y: State trait anxiety inventory scale; SAS: Self-rating anxiety scale.