key: cord-0733246-68xzssxa
authors: Addison, Sarah; Shirima, Damalie; Aboagye-Mensah, Emmanuela B.; Dunovan, Shanon G.; Pascal, Esther Y.; Lustberg, Maryam B.; Arthur, Elizabeth K.; Nolan, Timiya S.
title: Effects of tandem cognitive behavioral therapy and healthy lifestyle interventions on health-related outcomes in cancer survivors: a systematic review
date: 2021-08-06
journal: J Cancer Surviv
DOI: 10.1007/s11764-021-01094-8
sha: b2bb8befdd1e2d9c026e9ab1c4df2c9c9e11fe99
doc_id: 733246
cord_uid: 68xzssxa

PURPOSE: Healthy lifestyle (HL) behaviors and cognitive behavioral therapy (CBT) have been individually shown to improve adverse effects of cancer treatment. Little is known about how such programs in tandem affect health-related outcomes. This review evaluates extant literature on tandem CBT/HL interventions on health-related outcomes in cancer survivors. METHODS: A comprehensive search of PubMed, PsychINFO, CINAHL, and Embase databases revealed numerous studies involving CBT and HL tandem interventions in cancer survivors in the last 20 years. Studies meeting the inclusion criteria were examined and assessed by the authors. RESULTS: The 36 studies included 5199 participants. Interventions involved the use of CBT in combination with a HL condition (stress reduction, increasing physical activity, etc.). These tandem conditions were compared against no intervention, usual care, and/or CBT alone or HL alone. Interventions were delivered by a variety of interventionists, and over different durations. The most common HL target outcomes were stress, and insomnia. Most studies (31 of 36) reported a reduction in adverse treatment and/or cancer-related effects. CONCLUSION: Findings were biased with the overrepresentation of breast cancer survivors, and underrepresentation of minority groups, and those with advanced cancer. Thus, this review highlights the need for further research to test tandem interventions against CBT alone and HL alone, and toward identifying the most efficacious interventions for dissemination and implementation across diverse groups of cancer survivors. Implications for cancer survivors Tandem CBT/HL interventions can improve health-related outcomes for cancer survivors when compared to usual care, but there is a paucity of knowledge to suggest differential outcomes when compared to CBT or HL alone.

Cancer is a leading cause of illness and disability in the world today [1] . With the advent of early screening and innovative treatments extending survival, considerable progress has been made in extending the lives of cancer survivors [2] . A cancer survivor, as described by the National Comprehensive Cancer Network (NCCN), is defined as someone who has been diagnosed with cancer, and is still living [3] .

The number of cancer survivors in the USA is expected to be over 22 million by 2030 [2] . While this is cause for celebration, this brings the new challenge of minimizing the side effects and psychological burden associated with the aftermath of cancer. Depending on the cancer type, stage of cancer, and type of treatments, survivors may be faced with a sequalae of cancer induced and/or treatment related symptoms that linger from months to years (e.g., fear of cancer recurrence (FCR), cancer related fatigue, hot flashes, insomnia) [4] [5] [6] [7] [8] . These effects have a deleterious impact on quality of life in survivors [9] . Thus, the urgency of monitoring and ameliorating these conditions, as the diagnosis of cancer transitions from a fatal condition to a chronic illness, is vital [10] .

Cognitive behavioral therapy (CBT) is a psychological intervention used to alter dysfunctional behaviors and thought patterns. While CBT has been used traditionally for patients with mental health disorders, such as depression, or anxiety, it has been receiving more attention for its use in survivorship care. In fact, it has been shown to be the most successful psychological intervention in improving cancer related fatigue, and there is evidence suggesting that it may improve overall quality of life in cancer survivors [11] [12] [13] [14] [15] [16] [17] [18] . Despite these findings, the majority of cancer survivors have not discussed psychological interventions with their providers, nor have they used one [19] Similar to CBT, healthy lifestyle interventions have been instrumental in improving the quality of life of cancer survivors. The emerging data around healthy lifestyle behaviors (i.e., diet, physical activity, minimizing distress (stress management/spiritual management), sleep, alcohol, sunscreen use, tobacco use, and weight management) suggest promise to improve the side effects of cancer related treatments [3, 18, [20] [21] [22] [23] [24] [25] . For example, a recent study found that survivors who quit smoking had reduced levels of FCR compared to survivors who continued to smoke [26] . Unfortunately, the majority of cancer survivors do not meet recommended guidelines from public health entities for physical activity, nor healthy eating [27] [28] [29] [30] [31] . Moreover, recent studies describe the amount of cancer survivors who continue to smoke to be anywhere from 12 to 27% [27, 32, 33] . Given the evidence presented, it is not surprising that there may be a benefit in a combined health behavior-oriented and CBT program [13] . By adding the use of CBT, there may be a positive effect on the intentionbehavior gap that assists with achieving more sustainable change in survivors [34] .

Consequently, it is imperative that we identify and implement methodology and interventions that can be used to lessen the physical and psychological side effects of cancer treatment, while also improving the quality of life of survivors. Other systematic reviews and meta-analyses have analyzed the effectiveness of CBT in cancer survivors, or lifestyle interventions in cancer survivors, yet little is known about how such programs in tandem affect health-related outcomes. One systematic review highlighted the relationship between health promotion activities, and general psychological interventions in young adult cancer survivors. However, it was limited in that it focused solely on young adult survivors, and only evaluated two studies that included CBT as a component [35] . Another systematic review found "moderate" evidence suggesting increased adherence with physiotherapy when combined with CBT [36] . No review has summarized the data on the use of tandem lifestyle interventions and CBT in cancer survivors; however, structured appraisal on such interventions is needed. As such, the purpose of this review was to illuminate and evaluate the combined efficacy of CBT and lifestyle interventions on quality of life and clinical symptomatology in cancer survivors.

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 Statement and Checklist provided the methodological framework to enhance the rigor of this review [37, 38] . These guidelines directed the systematic preparation, extraction, appraisal, and reporting of information gathered from randomized studies. The conceptual frameworks used in this review were the cognitivebehavioral model for psychotherapy, quality of life (QOL) model, and aspects of a healthy lifestyle as defined by the NCCN [3, [39] [40] [41] [42] Search strategy A systematic search protocol was developed with a reference librarian. PubMed, PsychINFO, CINAHL, and Embase databases were searched for randomized studies involving the tandem use of CBT and HL interventions. The outcomes of treatment were not included in the search strategy. The search was limited to quantitative, randomized studies in adults ages 18-80 years old, published in English between 1990 and 2019. The year range was chosen to reflect the timeline surrounding CBT's use in clinical practice settings, as well as its initial use in cancer patients [42, 43] . The authors and the reference librarian iteratively optimized search strings from conceptual frameworks. They consisted of Boolean phrases of the following databasespecific indexed terms (i.e., MeSH, Emtree, subject headings, thesaurus, etc.): healthy lifestyle, lifestyle changes; health behavior, attitude to health, health attitudes, health beliefs; quality of life, health-related quality of life, psychological well-being; cognitive behavior therapy, CBT, cognitive therapy, behavior therapy; neoplasm(s), cancer, cancer survivor(s), cancer patient(s), cancer care facilities, and psycho-oncology.

The initial inclusion criteria for determining study eligibility were randomized studies involving cognitive behavioral therapy and lifestyle interventions (i.e., stress management, spiritual support, sleep hygiene, alcohol use, tobacco use, weight management, exercise, nutrition) for adult cancer survivors (i.e., from diagnosis through the remainder of life) with quantitative lifestyle and/or quality of life outcomes. Exceptions were made to include interventional studies that randomized to waitlist control groups or multiple intervention groups instead of simply being randomized to a control group from enrollment. Studies were excluded based on the following criteria: qualitative studies; literature reviews; non-interventional quantitative studies without random sampling; animal studies; pediatric population; intervention involving mindfulness-based stress reduction without CBT, and studies disseminated in a language other than English. Covidence® software facilitated the delimitation process and the creation of the PRISMA flow diagram (see Fig. 1 ) [44] . The identified abstracts and subsequently full-text studies were evaluated for eligibility criteria by a minimum of two authors independently. In the case of a conflict, all of the authors discussed and reached consensus for eligibility.

Data was extracted from the included studies by a minimum of two authors utilizing a data matrix with the following domains: author (year); purpose; sample; lifestyle focus and components of the intervention; delivery mode and length of intervention; control conditions; outcome measures; results; quality assessment score. Next, these domains were used to compare the included studies' data patterns and to identify relationships for data synthesis.

The included studies' methodological quality, sources of bias, and representativeness were critically appraised by a minimum of two authors using the National Institutes of Health's (NIH) Quality Assessment of Controlled Intervention Studies [45] . Each selected "yes," "no," or "cannot determine/not reported/not applicable" responses to a range of items addressing methodological rigor, internal validity, and sources of bias with respect to the included studies which collectively determined a percentage "yes" total score. Studies with a total score of < 50%, 50-75%, or > 75% were considered to be of poor, fair, or good quality, respectively (see Table 1 ). 

The search for studies meeting the criteria resulted in a total of 1494 studies. As denoted in Fig. 1 , 1437 of these were removed due to being a duplication, in a language other than English, or not meeting the eligibility criteria. Fifty-seven papers were then selected for full-text evaluation, and screened further. Of these, 36 studies met inclusion criteria and were evaluated (see Table 1 ). Of note, Goedendorp et al. is a secondary analysis of Goedendorp et al. [46, 47] . Both studies are included in this review.

The 36 studies included a total of 5199 participants. The majority of studies evaluated several different outcomes, which included quality of life, distress, FCR, insomnia, physical activity, smoking cessation, and other related measures. Thirteen of the 36 papers did not include a longitudinal assessment of participants postintervention [48] [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] . Of the 23 that did, the time range for follow up extended anywhere from two months, to 15 years [46, 47, .

In terms of length, interventions ranged from 4 weeks to 7 months. The interventions also varied in the method of delivery, including face to face, telephone, internet based, or some component of each. Most studies excluded those actively seeking treatment, with advanced cancer (> stage III), or with any type of metastasis. The quality of the studies, as assessed by reviewers, ranged anywhere from 28.5 to 100%.

Anxiety, depression, and/or stress management were the predominant (n = 13) focus of most interventions [53-55, 57, 58, 61, 67, 68, 73, 77, 78, 80, 81] . Following, was the use of CBT and HL interventions in the reduction of insomnia (n = 9) [48, 49, 56, 59, 64, 69, 74, 75, 79] , and fatigue (n = 7) [46, 47, 50, 51, 60, 70, 72] . Very few studies focused on cancer related cognitive changes (n = 2) [65, 66] , weight loss and diet (n = 1) [52] , and smoking cessation (n = 1) [62] .

In total, 13 studies concentrated on anxiety, stress, mood, and/or FCR [53-55, 57, 58, 61, 67, 68, 73, 77, 78, 80, 81] . The majority reported positive outcomes in the reduction of adverse emotional states. Many studies also included HL interventions that were heavily education-based, seemingly aimed at building long lasting stress reduction and coping skills in survivors. For instance, a 2006 study by Antoni et al. examined the use of stress reduction methods such as muscle relaxation, and the recitation of recorded relaxation exercises to facilitate the honing of coping skills in breast cancer survivors, in ten weekly, 2-h sessions [61] . The participants reported several positive outcomes postintervention, including "reduced reports of social disruption and increased emotional well-being," and greater confidence in their ability to relax at will. Many of these effects were sustained at a 12-month follow-up.

Similarly, in a randomized control trial conducted by Yanez et al., prostate cancer survivors took part in an intervention focused on mitigating depressive symptoms and increasing relaxation [80] . Specifically, the intervention involved "changing negative stressor appraisal… and building or enhancing social networks." At 6-month follow up, the participants reported clinically significant (p < 0.05) positive outcomes.

Only two studies focused on patients with advanced or terminal cancer [67, 80] . One of these, a 2012 study by Greer et al. consisted of a CBT intervention focused on reducing anxiety in those with terminal cancer. The results of the study indicated tremendous improvements in anxiety, but no difference in depressive symptoms between the intervention and control group at posttreatment. Weaknesses of this study include a lack of control for the use of psychotropic medication, and their overwhelmingly (95%) white cohort. A major strength of this study was that the authors tried to ensure that the CBT intervention took place on the same day as other medical visits participants had, to increase accessibility and the rate of retention. The rate of attrition was high in this study, at 30%, in large part due to participants being medically unable to continue, or passing away before the study's end.

Nine studies evaluated insomnia and/or sleep management as a primary outcome [48, 49, 56, 59, 64, 69, 74, 75, 79] . Many used a combination of CBT involving either sleep hygiene education, sleep restriction, and/or stimulus control components. All nine studies reported positive outcomes. Interestingly, to further elucidate the role of each CBT component in the management of insomnia and fatigue, a 2008 study by Dirksen et al. compared the use of CBT with components of sleep restriction, education, hygiene and stimulus control with a control group with only sleep education and hygiene for the treatment of insomnia in breast cancer survivors [49] . While both groups showed improvement in quality of life, the intervention group reported a greater reduction in fatigue than the control. The intervention group also reported statistically significant improvements in anxiety, and depression. However, longitudinal sustainability was not assessed, so whether or not these results endured is unknown.

Seven studies focused on increasing physical activity, and/ or the use of physical activity to reduce fatigue or increase functioning [46, 47, 50, 51, 60, 70, 72] . While positive outcomes were reported in all studies, only four of the seven directly analyzed the impact of the addition of CBT to physical activity in the reduction of cancer-induced and/or treatment-related symptoms [46, 60, 70, 72] .

One of these, a 2013 study from Prinsen et al., focused on CBT's effect on physical activity and postcancer fatigue [72] . The intervention itself incorporated the encouragement of realistic physical activity standards (i.e., walking or cycling), and CBT. The outcomes of the tandem intervention revealed a statistically significant change, compared to the waitlist control group. At the 6-month follow-up, the difference in fatigue between the intervention and control group was sustained; however, physical activity was found to be statistically insignificant when analyzed between the intervention and waitlist control group. Ultimately, the authors concluded that physical activity did not mediate CBT in reducing fatigue in these patients. Similarly, a 2010 study by Goedendorp et al. compared three conditions-a CBT/physical training based intervention, a brief nursing intervention focused on education, a "usual care" (UC) group to examine the best means of decreasing fatigue among cancer survivors [46] . The CBT/HL intervention focused on encouraging patients to engage in physical activity to minimize fatigue. A significant reduction in fatigue was found in the CBT/HL intervention group, when compared with the brief nursing intervention and UC groups. Despite this positive outcome, further analysis demonstrated that the introduction of physical activity did not mediate the decrease in fatigue.

Only one study focused on diet and weight loss. This study from Pakiz et al. lasted 12 months and aimed to foster "regular physical activity and reduced energy intake in order to facilitate weight loss" [52] . Participants received counseling over the phone, and took part in group meetings with rotating topics (i.e., "portion control, exercise, weight maintenance skills"). The intervention was efficacious, with the difference in weight loss between the control and intervention group found to be statistically significant "(− 5.7 [3.5] vs. 0.2 [4.1] kg, P < 0.001)". The intervention group also reported increased levels of physical activity and improvements in fitness; however, there was no follow-up scheduled at the end of the yearlong intervention, so it is difficult to determine whether or not these results were sustainable.

Only one study included smoking and alcohol cessation as an intervention focus [62] . The basis of this intervention was to reduce smoking, alcohol consumption, and depressive symptoms in head and neck cancer survivors. The intervention itself consisted of nurse-led CBT with "pharmacologic management as needed." This pharmacologic therapy consisted of treatments such as nicotine patches, and bupropion. The authors compared this patient set with those who received "enhanced" usual care. This "enhanced" care consisted of an equivalent amount of attention as the intervention group, and a referral "as needed for smoking cessation, and/or alcohol treatment, and/or psychiatric evaluation." The researchers discovered that the intervention condition increased smoking cessation by greater than 50%, when compared to care as usual. However, they also found that the intervention was not particularly efficacious in reducing alcohol consumption or depression compared to the control group. Of note, the criteria for a current smoker in this study included those who had reported quitting smoking within a month prior to the intervention [62] .

The CBT interventions were delivered by various means, with some studies using in-person groups, in-person one on one, Internet, phone-based interventions, or a combination of them all. A 2014 randomized control trial further probed this dynamic in breast cancer survivors, by exploring the efficacy of self-administered video based CBT (VCBT-I) compared to professionally administered interventions (PCBT-I), and a no treatment control group [59] . The authors concluded that "…PCBT-I was significantly more efficacious than VCBT-I in reducing ISI [Insomnia Severity Index] scores, EMA [early morning awakening], depression, fatigue, and dysfunctional beliefs about sleep." These results must be taken judiciously, however, considering that the PCBT-I patient received five more treatment sessions compared to the VCBT-I group. Also of note, was the rate of attrition-VCBT-I's dropout rate was more than double that of PCBT-I (13.6% compared to 28.8%).

Another distinction was the type of interventionist. The interventions were most commonly led by psychologists, master degree level psychology students, or clinical psychology fellows (n = 17) [53-55, 57-59, 61, 65-68, 71, 72, 75, 76, 78, 81] . However, many other interventions were led by nurses, therapists, social workers, physiotherapists, or research assistants given CBT training. One such study, performed by Lee et al., examined the efficacy of a "nurse-led" CBT intervention in increasing quality of life, and reducing fatigue in women currently undergoing radiotherapy for breast cancer [51] . The nurses ("registered nurse, student of master's degree in nursing"), received 36 h of training in cognitive behavioral therapy prior to the intervention. The results were favorable, with women in the intervention group experiencing less fatigue and greater quality of life than the control group. [70] . This condition was compared against a group of participants completing only physical training. Finally, both conditions were compared against a control group, who were provided no intervention. The authors found that the tandem intervention did not surpass physical training alone, in any of their measured outcomes (role limitations, quality of life). However, both conditions significantly outperformed the control group. Likewise, in the study by van Weert et al., the physical training (PT) condition outperformed the CBT/PT tandem intervention. Specifically, the authors found that "the PT group showed more reduction in 4 domains of fatigue, whereas the PT + CBT group showed more reduction in one domain only." [60] Analogously, a 2017 study performed by Irwin et al., found Tai Chi Chih to be noninferior to CBT with sleep education and hygiene components for the treatment of insomnia in breast cancer survivors [69] .

Similarly to intervention effectiveness, not all reported positive outcomes reached significance at follow-up. For instance, a 2015 study from Stefanopoulou et al., aimed at reducing hot flushes and improving quality of life in prostate cancer survivors, noted a significant positive improvement for the intervention group in hot flushes and night sweats problem rating and frequency at the end of treatment [76] . But, 26 weeks later, although the results were sustained, the differences between the care as usual group and the intervention group were not significant.

Overall, of the 23 studies that clearly assessed for longitudinal follow-up (> 2 months), 19 reported sustained positive effects in at least one measured outcome, two (Prinsen 2013 , Groarke 2013 reported that the positive outcomes were not sustained at 6 and 12 months, respectively, and another (Espie et al. 2008) , reported a diminished positive effect at six months. Finally, Goedendorp et al. (2012) reported reduced positive effects at seven months and a completely absent effect at 12 months [46, 47, .

Twenty-four out of the 36 studies either did not record racial demographic data, noted that the participants were "majority Caucasian," or had greater than 85% white participants [46-52, 56, 59, 60, 62-70, 72, 75, 77-79] . Notably, the 2012 study by Ritterband et al. reported only two black participants out of 28, with the authors remarking that the remaining 26 were mostly "highly educated Caucasian women" [56] . The lack of racial data in some instances is likely due to the country in which the study was conducted. These include studies from the Netherlands, China, South Korea, and Ireland. However, there were many US-based studies that either did not provide a racially diverse pool of participants, or did not report this data at all. In total, only eight of the 36 studies recorded 8% or greater black participants [53, 54, 57, 58, 61, 71, 76, 80] . Hispanics were poorly represented as well, with greater than 5% in only six studies, which includes one study with only Latinos [53-55, 57, 61, 81] .

Intervention adherence data was absent or unclear in the majority of studies, with only 11 out of 36 studies clearly referencing it, and many of those not providing associated data points [48, 59, 60, 63, 67-69, 71, 76, 77, 79] . Data on adherence is necessary to move forward with large scale trials on these tandem interventions.

As the landscape of cancer survivorship care shifts to focus on the lingering effects of cancer, so too must the treatments. As such, the aim of this review was to evaluate and consolidate information on the usefulness of tandem CBT and HL interventions in cancer survivors in hopes of informing clinical practice guidelines. Current survivorship guidelines advocate for the use of CBT and healthy lifestyle interventions (i.e., physical activity, alcohol cessation, etc.) to reduce cancer-induced and/or treatment-related symptom burden; however, little is known of the efficacy of a hybrid intervention [82] .

The results of this review revealed that the majority of included studies reported positive outcomes in at least one aspect, suggesting that there may be benefit in the use of tandem interventions in cancer survivors. However, very few studies compared the combination of CBT/HL against a HL intervention alone [60, 70] , or CBT/HL to CBT alone [46, 72] . This lack of direct comparison of each component of a multi-modal intervention makes it challenging to elucidate whether the addition of CBT, or a HL intervention to treatment regimens would be superior to a CBT or HL intervention alone, or merely redundant.

Additionally, due to the heterogeneous nature of each intervention, it is difficult to make generalizations about the integrity of comparisons. Major sources of variability include the duration, mode of delivery, and length of each intervention. For instance, participants in a 2008 study by Espie et al. met for five weekly 50-min sessions, while in another study, by Qiu et al., participants met weekly for 10 weeks, for sessions lasting 2 h each [64, 73] . This leaves us to question whether or not the positive outcomes could be due in part to the amount of contact, or intensity of treatment sessions. Moreover, despite the studies sharing common goals, the criteria and measurements used were not homogenous among the studies. This lack of consistency in outcome measurements makes rigorous comparisons difficult to perform. As such, the quality of evidence for the usefulness of tandem interventions in clinical practice is difficult to extrapolate.

Another emerging area of research in survivorship care involves increasing patient accessibility to survivorship related treatments and care, in hopes of broadening reach. Minimizing the amount of in person contact time needed may be one such avenue [83] . One way to practically achieve this is to allow patients to access these treatments remotely, on their own schedule, as done with recorded video-based interventions. As aforementioned, this was explored by a study in our cohort [59] . The authors concluded that although VCBT is more available, it was not as effective, or as well adhered to as CBT administered face-to-face. However, this may need to be evaluated further due to the impact of SARS-CoV-2, which has pushed healthcare systems to rapidly adopt tele-health and virtual platforms [84] . Nurse led interventions, may be another possibility in making these interventions adaptable for use in clinical practice. Notably, Lee et al. found their nurse led intervention to be more efficacious than "standard care." Though, this should be taken cautiously considering it was not directly compared to an equivalent physician or psychologist led intervention [51] However, considering that nursing has been named the most trusted profession for nearly 20 years straight, this should be an area of further study [85] . Moreover, considering that the average amount of time spent by physicians with cancer survivors in outpatient settings is 22.9 min, the use of a multidisciplinary team, consisting of psychologists, social workers, nurses, and other healthcare professionals, may be a more time efficient avenue for clinical practices to explore, and a more flexible and readily accessible option for patients to receive [86] .

The field also appears to be saturated with certain cancer types, while having a paucity of information on others. Breast cancer was the most common cancer type examined, as these survivors were the sole focus of 18 out of the 36 studies [48, 49, 51, 52, 58, 59, 61, 63, 65, 66, 68, 69, 71, 73-75, 79, 81] . Moreover, breast cancer patients also accounted for > 50% of participants in six additional studies [46, 47, 56, 60, 64, 70] . The second most common cancer type examined was prostate cancer, as the sole focus of six studies [53-55, 57, 76, 80] . On the other hand, head and neck cancers were the focus of only one study [62] . This is understandable, considering the high rates of breast and prostate cancer; however, it makes it difficult to take away generalizable evidence for other cancers from these findings [87] . As coping and maintaining health are important for all cancer types, it is disappointing that there is a limited pool of information on the use of multifaceted interventions in cancer types outside of breast and prostate cancer.

Also contributing to a lack of diversity, is the absence of studies focusing on, or even allowing the inclusion of those with terminal, and/or advanced cancers. Of the 36 studies in this review, only two were dedicated to those with advanced or terminal cancers [67, 80] . Yanez et al. conducted an intervention focused on improving distress, and reducing depressive symptoms in men with advanced (stage III or IV) prostate cancer at initial diagnosis, however those with "prior history of surgery or chemotherapy treatment within the past 6 months" were excluded [80] . This has been recently highlighted-with researchers pointing out the staggering absence of studies focused on improving the quality of life of metastatic cancer survivors despite a growing need for such examination [10] .

Overall, the evidence suggests that tandem interventions appear to be efficacious, but there is no consensus on the optimal dose or delivery mechanism. To provide tangible conclusions, the next step in the assessment of these tandem interventions may be the use of pragmatic and/or dissemination and implementation trials.

The strengths of this review include the use of randomization in all included studies, the screening of each study by a minimum of two independent evaluators, and the use of the NIH quality assessment tool by a minimum of two individual screeners to assess quality. Additionally, the rigor of the systematic search and data collection are significant strengths of this review. Accuracy was safeguarded by the use of PRISMA, as well as the involvement of multiple authors to gather outcomes. The authorship group met many times to discuss any discrepancies in consensus and ensure an iterative nature to data collection.

The most salient limitation is the lack of participant diversity of the included studies. This refers not only to the absence of racial diversity, but also in types and stages of cancer. Consequently, this homogeneity makes it difficult to generalize the findings to the average patient population. Also of note, many studies did not include adherence data. The absence of this information makes it challenging to uniformly deduce how much of a given intervention is needed to effect a positive outcome. Moreover, without this data, it is difficult to make thorough comparisons against other interventions, and to determine whether or not pursuing the clinical translation of these multifaceted treatment modalities would be a wise way to allocate resources in survivorship care.

Other limitations of this review include the possibility of publication bias, the variable quality of the studies included, and the exclusion of studies in a non-English language, and those focusing on a populations aged 18 and under. It is possible that the high number of positive outcomes could be due in part to publication bias. As such, it is possible that we would not have access to studies with more negative outcomes, as they would not have been published.

The exclusion of non-English studies, as well as those focusing on the pediatric population (0-17 years old), limits the breadth that can be gleamed from the findings. It is possible that informative studies, otherwise meeting our criteria, may not have been translated into English, and thus were excluded. The same holds true for studies focusing on pediatric patients. With these factors in mind, it is necessary to consider the scope of this systematic review before extrapolating results across a wider spectrum of individuals.

Furthermore, there was also a great deal of variability in mode of delivery and duration of interventions, with some studies including voluntary modules which were left up to the participants to complete and thus completed by some participants, but not others [48] . Such presentations make it difficult to draw conclusions or overarching inferences on the true efficacy of these tandem interventions. Finally, participants were also not blinded in any of the studies, and many studies did not control for attention, as they used waitlist controls or care as usual. Both of these stipulations are understandable given the nature of these interventions; however, it does reduce the rigor of evidence that can be gleaned from their results.

This review is the first to systematically review the extant literature on tandem CBT/HL interventions in the care of cancer survivors. While the results are promising, due to the heterogeneity of studies comparing CBT/HL to CBT only, or HL only, the overrepresentation of certain cancers, underrepresentation of Blacks, and other people of color, and variability of dose and delivery, conclusive evidence cannot be gleaned. While there is evidence emerging on the utility of such tandem interventions, it is difficult to make definitive suggestions for clinical practice guidelines. This serves to highlight the need for further research in this area.

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Cognitive-behavioral stress management improves stress-management skills and quality of life in men recovering from treatment of prostate carcinoma

A randomized clinical trial of group-based cognitive-behavioral stress management in localized prostate cancer: development of stress management skills improves quality of life and benefit finding

Cognitive behavioral stress management intervention improves quality of life in Spanish monolingual hispanic men treated for localized prostate cancer: results of a randomized controlled trial

Initial evaluation of an Internet intervention to improve the sleep of cancer survivors with insomnia

Identifying how and for whom cognitive-behavioral stress management improves emotional well-being among recent prostate cancer survivors

Brief cognitive-behavioral and relaxation training interventions for breast cancer: A randomized controlled trial

Is a video-based cognitive behavioral therapy for insomnia as efficacious as a professionally administered treatment in breast cancer? Results of a randomized controlled trial

Cancer-related fatigue and rehabilitation: a randomized controlled multicenter trial comparing physical training combined with cognitive-behavioral therapy with physical training only and with no intervention

How stress management improves quality of life after treatment for breast cancer

A tailored smoking, alcohol, and depression intervention for head and neck cancer patients

Efficacy of cognitive behavioral therapy and physical exercise in alleviating treatment-induced menopausal symptoms in patients with breast cancer: results of a randomized, controlled, multicenter trial

Randomized controlled clinical effectiveness trial of cognitive behavior therapy compared with treatment as usual for persistent insomnia in patients with cancer

Development of CBT for chemotherapyrelated cognitive change: results of a waitlist control trial

A randomized trial of videoconference-delivered cognitive behavioral therapy for survivors of breast cancer with self-reported cognitive dysfunction

A pilot randomized controlled trial of brief cognitivebehavioral therapy for anxiety in patients with terminal cancer

Cognitive-behavioural stress management enhances adjustment in women with breast cancer

Chi Chih compared with cognitive behavioral therapy for the treatment of insomnia in survivors of breast cancer: a randomized, partially blinded, noninferiority trial

Quality of life after self-management cancer rehabilitation: a randomized controlled trial comparing physical and cognitivebehavioral training versus physical training

Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial

The role of physical activity and physical fitness in postcancer fatigue: a randomized controlled trial

A randomized controlled trial of group cognitive behavioral therapy for Chinese breast cancer patients with major depression

Effects of cognitive behavioral therapy for depression on improving insomnia and quality of life in Chinese women with breast cancer: results of a randomized, controlled, multicenter trial. Neuropsychiatr Dis Treat

Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part I: Sleep and psychological effects

A randomised controlled trial of a brief cognitive behavioural intervention for men who have hot flushes following prostate cancer treatment (MANCAN)

Cognitive-behavioral intervention for distress in patients with melanoma: comparison with standard medical care and impact on quality of life

Efficacy of blended cognitive behavior therapy for high fear of recurrence in breast, prostate, and colorectal cancer survivors: the SWORD study, a randomized controlled trial

Internet-delivered cognitive-behavioral therapy for insomnia in breast cancer survivors: a randomized controlled trial

Feasibility, acceptability, and preliminary efficacy of a technology-assisted psychosocial intervention for racially diverse men with advanced prostate cancer

Long-term psychological benefits of cognitive-behavioral stress management for women with breast cancer: 11-year follow-up of a randomized controlled trial. Cancer

NCCN Guidelines for Patients Survivorship for Cancer-Related Late and Long-Term Effects

Internet-delivered insomnia intervention improves sleep and quality of life for adolescent and young adult cancer survivors

Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic -United States

Nurses Ranked Most Trusted Profession 19 Years in a Row

Visit duration for outpatient physician office visits among patients with cancer

Cancer Facts and Figures 2020