Effects of Peer-Led Interventions For Patients With Cancer: A Meta-Analysis

ADVANCED PRINT EXCLUSIVE
Effects of Peer-Led
Interventions for Patients
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With Cancer: A Meta-Analysis

Myung Kyung Lee, RN, PhD, OCN®, and Soon-Rim Suh, RN, PhD
PROBLEM IDENTIFICATION: To evaluate the effects
T
he earlier detection and treatment of
of peer-led supportive interventions (PSIs) for
many types of cancer has
patients with cancer. significantly extended the life
expectancies of patients during the
LITERATURE SEARCH: Six electronic databases past two decades (Siegel, Miller, &
(EMBASE, MEDLINE®, Google Scholar, Cochrane Jemal, 2015). How-
Library, ProQuest Medical Library, and CINAHL®) ever, cancer and its treatment can lead to physical
disability, emotional distress, and social problems.
were searched for articles published from 1997 to
Even after treatment, a cancer survivor often
May 2017. requires care from multiple providers to manage the
long-term sequelae of the illness and treatment.
DATA EVALUATION: A total of 159 studies were Patients with cancer who have prolonged survival
identified. Eighteen (16 randomized, controlled times often have unmet supportive care needs
trials [RCTs] and 2 non-RCTs) were eligible for (Hodgkinson, Butow, Hobbs, & Wain, 2007).
Patients with cancer who have less social support
systematic review and 16 for meta-analysis. The
during and after treatment are more likely to experi-
Cochrane risk of bias tool and Comprehensive Meta-
ence distress (Andrykowski, Lykins, & Floyd, 2008).
Analysis software were used for analysis. Social support can contribute to general well-being
and buffer the impact of stressful experiences,
SYNTHESIS: The authors synthesized the results including those related to life-threatening illnesses
of the effect size of each trial according to cancer (Cohen & Wills, 1985). Peer support is a common
symptoms, coping, emotional health, quality of life, form of social support because it provides patients
with opportu- nities for experiential empathy.
self-efficacy, sexuality, social support, and health-
Peer-led supportive interventions (PSIs), in which
related behaviors. individuals communi- cate and share experiences
with others who have had similar personal
IMPLICATIONS FOR RESEARCH: The findings from experiences, can help to build self- efficacy, or the
this study suggest that an additional tiered belief that one is capable of performing a course of
evaluation that has a theoretical underpinning and action to reach a desired goal (Bandura, 1997). Self-
efficacy is key to an individual’s successful self-
high-quality methodology is required to confirm
management of diverse chronic illnesses and,
the efficacy of PSIs within cancer care models. therefore, helps to improve health outcomes (Lorig
& Holman, 2003). In recognition of the importance
of social relationships and support from peers,
intimate partners, or family members,
experiential knowledge has become significant in
the delivery of quality health care (Cox, 1993; Eng &
Young, 1992).
Numerous studies of PSIs in the past 20 years
have examined their effects on physical problems,
psychosocial distress, unhealthy behaviors, and
coping skills. However, these studies have had
discordant results, and many have not satisfactorily
met the outcome expectations. For example,
previous trials in which
KEYWORDS peer; partner; intervention; meta-
analysis; cancer
ONF.ONS.ORG MARCH 2018, VOL. 45 NO. 2 ONCOLOGY NURSING FORUM 1

the intimate partner or family members participated
addition, these previous reviews (Campbell et al.,
as care providers showed inconsistent effects on sex-
2004; Hoey et al., 2008; Macvean et al., 2008) did
uality (Bultz, Speca, Brasher, Geggie, & Page, 2000;
not formally assess study heterogeneity. The small
Campbell et al., 2007; Porter et al., 2009).

number of RCTs included in these previous reviews
Studies in which breast cancer survivors who
is also a limitation.
completed primary treatment provided other
Performing a meta-analysis to determine the
patients with breast cancer with supportive
effects of a specific model of peer support (one-
interventions had inconsistent results regarding
on-one or face-to-face peer-led supportive care) is
quality of life (QOL), emotional health, and self-
necessary. The current meta-analysis examines pre-
efficacy (Giese-Davis et al., 2016; Lee, Lee, Oh, &
vious trials to quantify the ESs of different PSIs on
Kim, 2013; Napoles et al., 2015; Wittenberg et al.,
various outcomes of patients with cancer.
2010). In addition, PSIs that employed active
listening or sharing of experiences regarding the
emotional health of patients have had inconsistent Methods
results (Crane-Okada et al., 2012; Giese-Davis et The review was conducted according to the
al., 2016; Lee et al., 2013; Weber et al., 2004; PRISMA (Preferred Reporting Items for Systematic
Weber, Roberts, Yarandi, Mills, Chumbler, & Reviews and Meta-Analyses) guidelines (Liberati et
Algood, 2007; Weber, Roberts, Yarandi, Mills, al., 2009). All included studies were RCTs or non-
Chumbler, & Wajsman, 2007). The discordance RCTs that examined the effects of supportive
among these previous studies suggests that PSIs interventions led by the peers or partners of adults
may provide no clear benefit in facilitating aged 18 years or older who had been diagnosed
psychological adjustment or in aiding recovery with cancer; these interventions were compared
from the traumatic experiences of cancer. The with healthcare professional–led care or usual care.
conclusions of these previous studies may differ as a
result of heterogeneity in application of theory, Data Sources and Searches
control conditions, study design, characteristics The search strategy was developed in collaboration with
of peers, or intensity of the intervention. an experienced research librarian. Articles were identi-
Therefore, a more thorough synthesis of these fied through searches of MEDLINE®, EMBASE, Google
studies is needed to draw an integrated conclusion Scholar, Cochrane Library, ProQuest Medical Library,
on the effects of PSIs and to identify reasons for the and CINAHL® without search limits. Manual reviews
varying results. of reference lists from publications identified in these
Campbell, Phaneuf, and Deane (2004) databases were also performed. All searches included
reviewed 21 studies on PSIs (18 nonexperimental studies published in English from 1997 to May 2017. All
studies and 3 randomized, controlled trials [RCTs]). RCTs and non-RCTs of PSIs for patients with cancer
Hoey, Ieropoli, White, and Jefford (2008) also were included. The search terms were as follows, with
reviewed 43 studies on PSIs for patients with the syntax modified according to the guidelines of each
cancer (35 nonexperimental studies and 8 RCTs). database: (“Neoplasms” OR “Cancer”) AND
However, both reviews included diverse models of (“Peer” OR “Mentor” OR “Volunteer” OR “Lay”
peer-led support (one-on-one peer support, OR “Partner” OR “Supporter” OR “Coach” OR
group-based therapy without one- on-one “Navigator”) AND (“trial” OR “controlled trial” OR
support, and Internet-based peer support). “experimental study” OR “quasi-experimental
Macvean, White, and Sanson-Fisher (2008) reviewed study”).
28 nonexperimental studies and 4 RCTs that exam-
ined one-on-one support programs using volunteers; Study Selection
this review included homogeneous peer-led models, All included studies examined PSIs as the main
such as one-on-one support, but most of the RCTs intervention, in which the trained peers were not
were published before 1996, and the authors did not healthcare professionals and were cancer survivors
show the combined effect sizes (ESs) of the who had received treatment, laypersons in similar
trials. These reviews (Campbell et al., 2004; age groups, or intimate partners or family members
Hoey et al., 2008; Macvean et al., 2008) concluded of the patient. The PSIs took place as one-on-one
that benefits stemmed from peer support, as well as interactions, and the effects were measured on the
that contact with other cancer survivors provides patients with cancer who received the intervention.
practical, social, and emotional support. However, A broad definition of PSI was used, so that studies
this conclusion is not certain because these studies of all interventions designed to help patients with
used heterogeneous models of peer-led support, did cancer improve their physical and
not analyze ESs, and relied on data collected more
than 20 years ago. In
psychosocial outcomes (e.g., QOL, healthy
number of sessions; intervention period; duration
behavior, sexuality) were included. In all studies,
of each session, and follow-up times)
peer assistance was given individually to the person
The outcomes of the PSI were cancer symptoms,
with cancer, either via face-to-face or telephone

coping, emotional health, QOL, self-efficacy,
contact. For studies that reported the outcomes of
sexuality, social support, and health-related
patients and peers (Bultz et al., 2000; Campbell et
behavior.
al., 2007), only patient data were used. When the
peer-led intervention was provided to an
Risk of Bias
experimental group and a control group, but the
interventions had different intensities, the study was RCTs and non-RCTs were independently assessed
included (Pinto, Stein, & Dunsiger, 2015a, 2015b; for methodologic quality by the current authors
Schover et al., 2011). Studies were excluded if they using the risk of bias tool, developed by the
had the following characteristics: Cochrane Bias Methods Group (Higgins & Green,
ɐ They used group dynamics or a group-based 2011). Each study was evaluated according to four
format of peers with cancer. criteria: random sequence generation, allocation
ɐ The peer-led interventions were supplemental to concealment, blinding of data collectors, and
direct intervention from a healthcare blinding of outcome assessors. Each criterion was
professional. judged to have a high or low risk of bias. If a study
ɐ The patients with cancer were receiving hospice was determined to have a high risk of bias for any
or palliative care. one criterion, then it was considered to have a high
ɐ The peer-led support was a self-help group risk of bias overall (Violette et al., 2015). When
evaluating the risk of bias was difficult (such as
(participants were included in a group of
when no information was available concerning
individuals with similar illness and received
allocation concealment or the methods of blinding
support from those group members) or was
or randomization, or when the information was
Internet-based.
insufficiently detailed), the current authors judged
All retrieved titles and abstracts were added to
the risk of bias to be uncertain.
a reference management database and screened for
duplicates. Titles and abstracts of articles were read
to identify and exclude those articles not meeting Statistical Analysis
the inclusion criteria. Then, articles appearing to The treatment and control groups were compared by
meet the criteria were read in full by the research calculation of standardized mean differences (SMDs)
assistant and the current authors. During this and 95% confidence intervals (CIs). Means and stan-
independent reading of articles, the current authors dard deviations, frequencies, and percentages before
determined the final selection of articles, and and after the interventions were used to
reference lists of these articles were reviewed to calculate SMDs (Cohen’s d) (Becker, 1988). All ESs
identify other potential articles. A standard data reported in this study were calculated using Cohen’s
extraction form was used to screen the titles and d. A Cohen’s d of 0–0.3 indicates a small ES,
abstracts of each article to ensure they met the 0.3–0.6 indicates a moderate ES, and greater than
eligibility criteria. An independent nurse method- 0.6 indicates a large ES (Cohen, 1988). Each ES was
ologist resolved disagreements regarding eligibility weighted by the inverse of its variance for
and verified the studies that were ultimately calculating the SMD. This approach gives more
selected. The institutional review board at weight to studies with larger sample sizes and
Kyungpook National University in Daegu, South reduces the imprecision of the pooled-effect
Korea, approved the study. estimate (Higgins & Green, 2011). The results across
studies were pooled using the DerSimonian-Laird
Data Extraction random effects model, in which tau was estimated by
the method of moments (DerSimonian & Laird,
The following data were extracted from each study: 1986). I2 was used to describe heterogeneity among
ɐ Author studies, and its value identified studies as having low
ɐ Year of (0–0.25), moderate (0.26–0.75), or high
publication ɐ Patient heterogeneity (0.76–1) (Higgins, Thompson, Deeks,
nationality ɐ Study & Altman, 2003). The current authors assumed
design real differences among the studies as well as
ɐ Type of cancer sampling errors and, therefore, conservatively
ɐ Sample size used the random effects model. A meta-analysis
ɐ Control conditions for a particular outcome was conducted when data
ɐ PSI details (peer characteristics, training, and were available from at least two studies.
counseling experience; content of intervention;
theoretical framework; intervention method;
Subgroup analyses were used for separate analyses
were unable to retrieve these data, even after
of studies according to the following characteristics:
contact- ing the author (Schover et al., 2006, 2011).
ɐ Study design These two studies were excluded.
ɐ Counseling experience of peers A funnel plot of precision versus SMD was used
ɐ Application of a theoretical framework to assess the potential of publication bias. The
ɐ Role of healthcare professionals during the peer absence of bias yields a plot resembling a symmetrical
intervention funnel; the presence of bias, which could occur if
ɐ Presence of a certain supportive action (such as studies with small sample sizes and no statistically
counseling) by a healthcare professional for significant effects were not published, yields an
peers who possibly experience trauma symptoms asymmetrical funnel with a gap in a bottom corner
or burnout (Higgins & Green, 2011). Egger’s regression test was
ɐ Type of peers (intimate partners or cancer complementarily used to determine the publication
survivors) bias (Egger, Davey Smith, Schneider, & Minder,
ɐ Control conditions 1997). Meta-analysis was conducted using
ɐ Risk of bias Comprehensive Meta-Analysis software, version 3.0. A
ɐ Methods of communicating between the peer p value of less than 0.05 was considered to be
statistically significant, and all statistical tests were
groups and the recipients
Two studies did not report statistics of the experi- two-sided.
mental and control groups, and the current authors
Findings
Literature Search and General Characteristics
FIGURE 1. Studies Examining the Effects The current authors initially identified 8,977 reports
of Peer-Led Supportive Interventions on Patients from the six databases. After screening titles,
abstracts, and full texts, the current authors selected
With Cancer, Determined by PRISMA Criteria
16 RCTs and 2 non-RCTs for inclusion (see Figure 1).
Tables 1 and 2 describe the characteristics of these 18
Records identified studies. Fifteen studies were conducted in North
through database America (Canada and the United States), 2 in South
Korea, and 1 in Australia. Ten studies were published
searching (n =
within the past 10 years, the mean age of study
8,977)
participants ranged from 45–63 years, the sample size
Records excluded after ranged from 30–367 participants, and the total
rough review of study number of patients was 2,254. Most studies examined
design, topic, and patients with breast cancer (n = 12), followed by
Records after publication type prostate cancer (n = 4), gastrointestinal cancer (n =
Records screened
duplicates removed 1), and multiple cancers (n = 1). The interventions
(n = 2,483)
(n == 3,664)
(n 1,181) were implemented at the time of diagnosis, after
surgery, after surgery and ongoing adjuvant
Records excluded after treatment, after primary treatment, or after cancer
Articles retrieved for title and abstract review recurrence.
full-text evaluation (n = 1,063)
(n = 118) Risk of Bias
The risk of bias, assessed using Cochrane
criteria, indicated that 15 studies had a high risk of
Additional articles Articles excluded for bias and three had a low risk of bias (see Table 3).
identified by manual failure to meet All 16 RCTs adequately randomized the enrolled
search (n = 41) inclusion criteria (n = patients. Six trials were classified as having used
141) adequate concealment, 13 trials as having used
adequate blinding of data collectors, and 10 trials as
Total studies included having used adequate blinding of the outcome
(N = 18) assessor. No trial reported whether the data
analysts were blinded.
PRISMA—Preferred Reporting Items for Systematic Reviews
and Meta-Analyses Description of Intervention and Control Conditions
The PSIs were designed to provide psychosocial sup-
port (Ashbury, Cameron, Mercer, Fitch, & Nielsen,
1998; Bultz et al., 2000; Campbell et al., 2007;
TABLE 1. Characteristics of Included Studies Examining the Effect of PSIs on Patients With Cancer
Study and Location Cancer Type Control Arm PSI Peers

Ashbury et al., Breast cancer 192 patients (mean age of 56 175 patients (mean age of 55 60 breast cancer
1998 (Canada) years) received no intervention. years) participated in a survivors
psychosocial program.
Bultz et al., 2000 (Canada) Breast cancer19 patients (mean15age
patients
of 50 years)
(mean age of 50 years) received mutual
15 spouses
psychosocial
or inti-support.
mate partners
received usual care following waitlist control.
Campbell et al., Prostate cancer 18 patients (mean age of 61 12 patients (mean age of 63 12 spouses or inti-
2007 (United years) years) received coping skill mate partners
States) received usual care. training.
62 patients participated
Chambers
in a nurse-led
et al., 2015
cognitive-behavioral
(Australia)Prostate cancer
sexuality intervention, and
63 patients
64 received
(mean
educational
age of 6315
materials;
prostatethe
cancer
meanyears)
age was
receiv
63
sexuality support.
Crane-Okada et al., Breast cancer 33 patients (mean age of 61 103 patients (mean age of 6 senior peer counsel-
2012 (United years) 62 years) received ors without a history
States) received no intervention. psychosocial counseling. of breast cancer
Giese-Davis
Breast cancer52
et al., 2016
patients
(Canada)
(mean age of 52 years)52 patients (mean age of 55 years)30 breast cancer received usual care.received psychosocial
Gotay et al., Breast cancer 124 patients (mean age of 128 patients (mean age of 12 breast cancer
2007 (United 55 53 years) received a quality- survivors
States) years) received usual care. of-life intervention.
Lee et al., 2013 (South Korea) Breast cancer65 patients (mean64age
patients
of 45 years)
(mean age of 46 years) received a psychosocial
13 breastinterven-
cancer survivors
tion.
received usual care.
Napoles et al., Breast cancer 75 patients (mean age of 50 76 patients (mean age of 51 3 culturally simi-
2015 (United years) years) participated in a lar breast cancer
States) received usual care following cognitive-behavioral stress survivors
waitlist control. management program.
Pinto et al., 2015a,
Breast 2015b
cancer37
39 patients
patients
(mean
(mean
ageage
of of
5656
years) participated in a physical activity intervention, plus18
thebreast
American
cancer
Cancer
survivors
Society Reac
(United States)
years) participated in the American Cancer Society Reach to Recovery program.
Porter et al., Gastrointesti- 65 patients (mean age of 59 65 patients (mean age of 59 65 spouses or inti-
2009 (United nal cancer years) received brief cancer years) received an emotional mate partners
States) education and support for disclosure intervention.
couples.
Samarel et al., States) without peer
Breast cancer 64 patients
1997 (United coaching.
(mean age of 53 years)
States)
participated Breast cancer 21 patients
in cancer (mean age of 49 years)
Schover et al., support received usual
2006 (United groups care following
wa breast cancer
58 patients (mean age of 53 years) participated in a 58 spouses, family
itli survivors
coaching-based psychosocial intervention. members, and friends
st
co 27 patients (mean age of 49 years) received
nt culturally sensitive sexuality counseling with 3 culturally
rol workbook. similar

.
Continued on the next page

TABLE 1. Characteristics of Included Studies Examining the Effect of PSIs on Patients With Cancer (Continued)
Study and Location Cancer Type Control Arm PSI Peers

Schover et al., 2011 Breast cancer 148 patients (mean age of 152 patients (mean age of 54 27 culturally similar
(United States) 54 years) received brief years) received culturally sensitive breast cancer sur-
telephone counseling with sexuality counseling with workbook. vivors
workbook.
Weber et al., Prostate cancer 15 patients (mean age of 60 15 patients (mean age of 58 10 prostate cancer
2004 (United years) years) received a psychosocial survivors
States) received usual care. intervention.
Weber
Prostate
et al.,
cancer35
2007a (United
patients
States)
(mean age of 60 years)37 patients (mean age of 60 years)37 prostate cancer received usual care.received psychosocia
Wittenberg et al., Breast cancer 34 peers/breast cancer 39 patients (mean age of 51 39 breast cancer
2010 (United survivors years) participated in a navigator survivors
States) (mean age of 55 years) providing program.
the psychosocial intervention
Yun et al., 2017 Various types of 72 patients (mean age of 51 years) 134 patients (mean age of 51 37 cancer survivors
(South Korea) cancer received health education. years) participated in a physical (various types)
activity, dietary habits, and distress
management program.
a
Refers to Weber, Roberts, Yarandi, Mills, Chumbler, & Algood (2007) and Weber, Roberts, Yarandi, Mills, Chumbler, & Wajsman
(2007) PSI—peer-led supportive intervention
Note. All studies are randomized, controlled trials, with the exception of Ashbury et al. (1998) and Wittenberg et al. (2010).
Crane-Okada et al., 2012; Giese-Davis et al., 2016; and the duration of sessions ranged from 4–24 weeks (X— =
10.9
Lee et al., 2013; Napoles et al., 2015; Porter et al.,
2009; Samarel, Fawcett, & Tulman, 1997; Weber et
al., 2004; Weber, Roberts, Yarandi, Mills, Chumbler,
& Algood, 2007; Weber, Roberts, Yarandi, Mills,
Chumbler, & Wajsman, 2007; Wittenberg et al.,
2010), sexuality support (Chambers et al., 2015;
Schover et al., 2006, 2011), health behavior support
(Pinto et al., 2015a, 2015b; Yun et al., 2017), and
QOL support (Gotay et al., 2007). The types of
peers used for the PSIs were cancer survivors,
individuals of a similar age, spouses, intimate
partners, family members, and friends. All
interventions were conducted by trained peers.
Thirteen studies reported the training time for peers
(range = 2–48 hours) or the number of training ses-
sions for peers (range = 3–8 sessions). The peers’
ages were reported in 10 studies (range = 53–68
years, X— = 59 years). Six studies reported that
the peers had counseling experience. Thirteen
studies reported that healthcare professionals
had roles in monitor- ing, supervising,
educating, facilitating, ensuring quality control, or
mentoring in regard to the peers’ interventions.
The PSIs varied greatly in terms of the number
of sessions and their timing. In particular, the
number of sessions ranged from 3–24 (X— = 8.8),
weeks). Ten studies reported the
length of each session, which
ranged from 20 minutes to 2 hours;
in some cases, the participants
determined the length of each
session. The PSIs occurred as
face-to-face interactions in nine
studies, as telephone calls in five
studies, through a combination of
face-to-face interactions and
telephone calls in two studies,
and through a combination of
face-to-face interactions,
telephone calls, and email
messages in two studies. A
theoretical framework (cognitive-
behavioral theory, Rogers’s person-
centered counseling, Bandura’s
self-efficacy theory, social-cognitive
theory, the transtheoretical model,
Roy adaptation model, leadership
model) was used for the interven-
tions in 10 studies. Seventeen of the
18 studies used more than two
follow-up assessments. Members
of the control groups received
attentional control (Chambers et
al., 2015; Pinto et al., 2015a,
2015b; Porter et al., 2009; Samarel
et al., 1997; Schover et al., 2011;
Wittenberg et al., 2010; Yun et al.,
2017), no intervention (Ashbury et
al., 1998; Crane-Okada et al., 2012),
usual care following assignment
to a waiting list (Bultz et al., 2000;
Napoles et al., 2015; Schover et al.,
2006), or usual care (Campbell et
al., 2007; Chambers et al., 2015;
Giese-Davis et al., 2016; Gotay et al.,
2007; Lee et al., 2013; Weber et al.,
2004; Weber, Roberts, Yarandi,
Mills, Chumbler, & Algood,
2007; Weber, Roberts, Yarandi, Mills, Chumbler, &
interaction, and quality of relationship with spouse.
Wajsman, 2007).
Six studies examined social support outcomes based
on functional social support and desire to learn from
Patient Outcomes
cancer resources.
The included studies used diverse instruments to
measure patient outcomes. Five studies evaluated Effect of Peer-Led Supportive Interventions
cancer symptoms by recording fatigue, bowel symp-
on Patient Outcomes
toms, hormonal symptoms, urinary symptoms,
breast cancer–specific symptoms, symptom Table 4 shows the combined ES (SMD) of each
distress, appe- tite loss, constipation, diarrhea, trial and the ES of each trial regarding cancer
dyspnea, insomnia, nausea, vomiting, and pain. symptoms (n = 6), coping (n = 7), emotional health
Seven studies evaluated coping by measuring (n = 11), QOL (n = 10), self-efficacy (n = 5),
cognitive avoidance, fatalism, “fighting spirit,” sexuality (n = 7), social support (n = 6), and
helplessness, hopelessness, impact of cancer, post- health-related behaviors (n = 2). The ESs of the
traumatic growth, coping responses, cancer-specific 16 studies ranged from
trauma symptoms, and intrusive thoughts. –0.11 (95% CI [–0.41, 0.19]) for Chambers et al.
Eleven studies evaluated emotional health by (2015) to 0.89 (95% CI [0.45, 1.34]) for
measuring anger-hostility, anxious preoccupa- Wittenberg et al. (2010). The weighted average
tion, confusion-bewilderment, depression- (w) indicated a small ES (wES = 0.2; 95% CI
dejection, tension-anxiety, vigor-activity, anxiety, [0.12, 0.29]; p <
depression, psychosocial distress, somatization, 0.001). The heterogeneity was significant and
blaming others, and blaming oneself. Two studies moderate (p < 0.001, Q [15] = 31.7, I2 = 53%).
evaluated health- related behaviors by Analysis of the six studies that measured cancer
examining dietary habits, physical activity, and symptoms indicated no significant heterogeneity (p
adherence to medication or treatment. Ten = 0.629, Q [5] = 3.5, I2 = 0%); pooling of these six
studies evaluated QOL using various tools: studies indicated that the PSI group had symptoms
the Functional Living Index–Cancer, Functional similar to the control group (wES = 0.00; 95% CI
Assessment of Cancer Therapy, Expanded Prostate [–0.18, 0.17]; p = 0.966). Analysis of the seven
Cancer Index Composite, physical function and studies that measured coping indicated that the
mental health scales of the SF-36®, Inventory of PSI group had a small improvement relative to the
Functional Status–Cancer, Ryff Happiness Scale, control group (wES = 0.18; 95% CI [0.02, 0.34]; p
Quality of Life Index, UCLA Prostate Cancer Index, = 0.025); no significant heterogeneity was observed
and European Organisation for Research among these studies (p = 0.326, Q [6] = 6.9, I2 =
and Treatment of Cancer Quality of Life 14%). Analysis of the 11 studies that measured
Questionnaire. These tools were employed to emotional health indicated that the PSI group had a
measure functional well-being (functional status, small improvement relative to the control group
physical function, bowel function, hormonal (wES = 0.23; 95% CI [0.04, 0.41]; p = 0.017); the
function, urinary function, breast cancer–specific heterogeneity among these studies was moderate
function, social function, social activity, role and significant (p = 0.027, Q [10] = 20.2, I2 = 50%).
function, cognitive function); overall well-being Analysis of the 10 studies that measured QOL
(global health status, overall QOL, enjoyment of life, indicated that the PSI group had a small
family satisfaction, socioeconomic satisfaction, improvement relative to the control group (wES =
family satisfaction, physical well-being, emotional 0.15; 95% CI [0.03, 0.27]; p = 0.012); no significant
well-being, social and family well-being, breast heterogeneity was observed among these studies (p
cancer–specific well-being); and relationship = 0.411, Q [9] = 9.3, I2 = 3%). Analysis of the five
quality (relationship with doctor, desire to see studies that measured self-efficacy indicated that the
and be with family and friends, quality of PSI group had a moderate improvement relative to
interpersonal relationships). Five studies the control group (wES = 0.43; 95% CI [0.16, 0.69];
evaluated self-efficacy based on activity efficacy, p = 0.001); no significant heterogeneity was
coping efficacy, symptom management efficacy, observed among these studies (p = 0.218, Q [4] =
self-efficacy regarding cancer, self-efficacy for 5.8, I2 = 31%). Analysis of the seven studies that
self-management, and emotional self-efficacy. measured sexuality indicated that the PSI group
Seven studies evaluated sexuality based on had a small improvement relative to the control
measurement of marital satisfaction, sexual func- group (wES = 0.27; 95% CI [0.00, 0.54]; p = 0.048);
tion, intimacy with the spouse, masculine self- the heterogeneity among these studies was
esteem, sexual needs, sexual self-confidence, significant and moderate (p = 0.047, Q [6] = 12.8, I2 =
marital 53%). Analysis of the six studies that measured social
TABLE 2. Characteristics of Peer-Led Supportive Interventions Used in the Included Studies
Study Characteristics of Peer-Led Supportive Intervention Time of Measurement

Ashbury et al., 1998 Peer training; had experienced peer counselor; professionals monitored; face-to-face Postintervention
intervention
Bultz et9–12
al., 2000
hours of peer training; face-to-face intervention; 6 sessions took place during 6Baseline, 6 weeks, and 3 weeks (1.5–2 hours each).mo
Campbell et al., 2007 6 hours of peer training; mean age of peers was 59 years; professionals Baseline and 6 weeks
supervised; used cognitive-behavioral theoretical approach; face-to-face
intervention; 6 sessions took place during 6 weeks (1 hour each).
Chambers et al., 2015 12 hours of peer training; mean age of peers was 65 years; professionals Baseline, 3 months, 6
supervised and monitored; telephone intervention; 6 or 8 sessions took place from months, and 12 months
recruitment to 22 weeks postsurgery.
Crane-Okada et al., 2012 20 hours of peer training; mean age of peers was 66 years; had experienced Baseline, 5 weeks, 6
peer counselor; professionals supervised; used senior peer counseling months, and 12 months
guidelines and Rogers’s person-centered counseling; telephone intervention; 5
sessions took place during 5 weeks.
Giese-Davis et al., 2016 Peer training; mean age of peers was 54 years; professionals supervised; peer Baseline, 3 months, 6
support available; telephone, email, or face-to-face intervention; 24 sessions took months, and 12 months
place during 6 months.
Gotay et al., 2007 Peer training; had experienced peer counselor; telephone intervention; 4–8 Baseline, 3 months, and
sessions took place during 1 month. 6 months
Lee et al., 2013 32 hours of peer training; mean age of peers was 53 years; professionals Baseline and 6 weeks
supervised; peer support available; used Bandura’s self-efficacy theory; face-to-
face or telephone intervention; 6 sessions took place during 6 weeks (at least
20 minutes each).
Baseline, 3 months, and
Napoles et al., 2015 24 hours of peer training; professionals monitored and supervised; used 6 months
social- cognitive theory; face-to-face intervention; 8 sessions took place during 8
weeks (90 minutes each).
Pinto et al., 2015a,
Peer training; mean age of peers was 55 years; peers had an average of 4.4 Baseline, 12 weeks, and
2015b
years of counseling experience; used social-cognitive theory and transtheoretical 24 weeks
model; telephone intervention; 12 sessions took place during 12 weeks.
Porter et al., 2009 4 sessions of peer training; mean age of peers was 60 years; professionals
Baseline and 8 weeks
educated; used cognitive-behavioral couple therapy; face-to-face intervention; 4
sessions took place during 8 weeks (75 minutes for first session and 45
minutes for others).
8 sessions of peerSamarel
training;etprofessionals
al., 1997 facilitated; used Roy adaptation model; face-Baseline, 8 weeks, and to-face or telephone intervention; 8 s
Schover et al., 2006 3 months of peer training; had experienced peer counselor; face-to-face Baseline, 6 weeks, and 3
intervention; 3 sessions took place during 6 weeks (1–1.5 hours each). months
Schover et al., 2011 5 days of peer training; had experienced peer counselor; professionals ensured Baseline, 6 weeks, 6
quality control; face-to-face intervention; 3 sessions took place during 6 weeks months, and 12 months
(1–1.5 hours each).
Weber et al., 2004 2 hours of peer training, mean age of peers was 68 years; professionals Baseline, 4 weeks, and 8
monitored, used Bandura’s self-efficacy theory; face-to-face intervention; 8 weeks
sessions took place during 8 weeks.
Continued on the next page

TABLE 2. Characteristics of Peer-Led Supportive Interventions Used in the Included Studies (Continued)
Study Characteristics of Peer-Led Supportive Intervention Time of Measurement

Weber, Roberts, Yarandi, Peer training; used Bandura’s self-efficacy theory; face-to-face intervention; 8 ses- Baseline and 8 weeks
Mills, Chumbler, & sions took place during 8 weeks.
Algood, 2007; Weber,
Roberts, Yarandi, Mills,
Chumbler, & Wajsman,
2007
Wittenberg et al., 2010 3–6 peer training sessions; mean age of peers was 55 years; professionals
Baseline, 3 months, 6
supervised; peer support available; telephone, email, or face-to-face
months, and 12 months
intervention; at least one contact (46 minutes each) took place per week for
3–6 months.
Baseline, 3 months, 6
Yun et al., 2017 48 hours of peer training; mean age of peers was 56 years; professionals
months, and 12 months
mentored and supervised; peer support available; used transtheoretical and
leadership models; telephone intervention; 16 sessions took place during 6
months (30 minutes each).
support indicated that the PSI group had no signifi-

0.026), when the control group received usual care
cant improvement relative to the control group (wES
or an intervention (wES = 0.16; 95% CI [0.02, 0.3];
= 0.11; 95% CI [–0.19, 0.42]; p = 0.467); the hetero-
p = 0.028), when peers were cancer survivors
geneity among these studies was significant and
(wES = 0.17; 95% CI [0.02, 0.32]; p = 0.025), and
moderate (p = 0.002, Q [5] = 19.2, I2 = 74%). Analysis
when the PSI
of the two studies that measured healthy
was delivered through face-to-face interactions (wES
behavior indicated that the PSI group and the
= 0.66; 95% CI [0.3, 1.01]; p < 0.001). PSIs had a
control group had similar outcomes (wES = 0.07;
sig-
95% CI [–0.2, 0.33]; p = 0.626); no significant
nificant effect on self-efficacy when a theory-
heterogeneity was observed between these studies
based intervention was applied (wES = 0.53; 95% CI
(p = 0.654, Q [1] = 0.2, I2 = 0%).
[0.28, 0.77]; p < 0.001). PSIs had a significant effect
on sexuality when the peers were spouses or
Subgroup Analyses
intimate partners (wES = 0.53; 95% CI [0.18, 0.89]; p
The current authors also performed subgroup analy- = 0.003) and when
ses of studies that did or did not apply a theoretical the PSI was delivered through face-to-face
framework, used different control conditions, interactions (wES = 0.34; 95% CI [0.01, 0.67];
used different study designs, used peers with or p = 0.042).
without counseling experience, had roles for PSIs also had a significant effect on social support
healthcare professionals during the intervention, when the peers had counseling experience (wES =
did or did not provide supportive action for peers 0.44; 95% CI [0.1, 0.78]; p = 0.012).
who experienced trauma symptoms, had different
types of peers (spouse versus cancer survivor), Publication Bias
and had different levels of bias (see Table 5). The
A funnel plot of all 16 studies was symmetric (studies
results indicate that PSIs had a significant effect
with high precision are plotted near the average, and
on coping when they employed a theory-based
studies with low precision are spread evenly on both
intervention (wES = 0.21; 95% CI [0.01, 0.42]; p =
sides of the average), indicating no evidence of
0.037). PSIs also had a significant effect on
potential publication bias. The results of Egger’s
emotional health when the control group received
regression test support this conclusion (bias = 0.94, t
usual care or no intervention (wES = 0.24; 95% CI
= 1.28, df = 14, p = 0.223).
[0.05, 0.43]; p = 0.012), when the study
had a low risk of bias (wES = 0.3; 95% CI [0.03, 0.57];
p = 0.031), and when the PSI was delivered through
Discussion
face-to-face interactions (wES = 0.47; 95% CI [0.18, The purpose of this meta-analysis was to provide an
0.75]; p = 0.001). PSIs had a significant effect initial assessment of the effect of PSIs on the out-
on QOL in the RCTs (wES = 0.16; 95% CI [0.02, 0.3]; comes of patients with cancer. Overall, PSIs
p= appeared to provide small benefits (ES = 0.2). More
specifi- cally, PSIs had moderate effectiveness in
improving self-efficacy and small effectiveness in
improving sexuality, emotional health,
coping, and QOL. Previous
reviews suggested that peer support had a positive
examined in the current study mostly recruited
effect on psychological adaptation, either directly
patients through hospitals, and eligibility was based
(by decreasing feelings of isolation, encouraging
primarily on diagnosis, treatment status, or disease
healthy behaviors, and promoting positive

status. Patients with cancer who have low levels of
psychological states) (Macvean et al., 2008; Newell,
psychological distress, who are not open to receiv-
Sanson-Fisher, & Savolainen, 2002) or indirectly
ing support, or who have adequate social support at
(by buffering the impact of stress on health,
baseline are less likely to experience psychosocial
reframing threat apprais- als, and improving coping
improvements (Crane-Okada et al., 2012; Schover
responses and behaviors) (Hoey et al., 2008).
et al., 2011). A related reason for these small ESs is
The current authors can suggest several reasons
that the optimal intensity and timing of the PSI may
why the PSIs had small ESs on sexuality, emotional
differ among individuals (Crane-Okada et al.,
health, coping, and QOL. No RCTs screened for par-
2012). As treatment progresses, patients with cancer
ticipants’ willingness to receive support. The trials
may learn from whom they need support, when they
need
TABLE 3. Risk of Bias in Included Studies Determined by the Risk of Bias Tool From the Cochrane
Bias Methods Group
Allocation Blinding Blinding
Study RSG Concealment of DCs of OAs Risk of Bias
Ashbury et al., 1998 No No No No High
Campbell et al., 2007 Yes No Yes No High
Crane-Okada et al., 2012 Yes No Yes Yes High
Gotay et al., 2007 Yes Yes Yes Yes Low
Napoles et al., 2014, 2015 Yes Yes Yes Yes Low
Porter et al., 2009 Yes Uncertain Yes Yes High
Schover et al., 2006 Yes Uncertain Yes Yes High
Weber et al., 2004 Yes Uncertain Uncertain Uncertain High
Wittenberg et al., 2010 No No No No High
Yun et al., 2017 Yes No Yes Yes High

a
Refers to Weber, Roberts, Yarandi, Mills, Chumbler, & Algood (2007) and Weber, Roberts, Yarandi, Mills, Chumbler, &
Wajsman (2007)
DC—data collector; OA—outcome assessor; RSG—random sequence generation
ONF.ONS.ORG MARCH 2018, VOL. 45 NO. 2 ONCOLOGY NURSING FORUM 11

support, and the type of support they need. The
PSI on sexuality was stronger when the peers were
intensity and timing of the PSI should be tailored to
spouses or intimate partners (ES = 0.53) rather than
a patient’s individual needs.
cancer survivors (ES = 0.27). Most people consider
The current authors further analyzed the

sexuality to be a private issue and may be unwilling
small ESs of the PSI by performing subgroup
to discuss this topic with individuals who are
analyses. Subgroup analyses indicated that the effect
not spouses or intimate partners. The PSIs led by
of the PSI on sexuality, emotional health, coping,
cancer survivors may have a positive effect on
self-efficacy, QOL, and social support was
sexuality when the intervention is guided by
stronger for studies with theoretical
educational materials, even though participants may
underpinnings, when the quality of the
be unwilling to discuss sexuality issues (Schover
methodology was high (such as use of an RCT
et al., 2006). The current authors’ subgroup
design and a low risk of bias), when the intervention
analysis of the effect of PSIs on QOL indicated
was delivered through face-to-face interactions,
that the use of cancer survivors (rather than
or when the peers had counseling experience.
spouses or intimate partners) as peers may
Findings from the current study indicate that
improve outcomes. One study tested the efficacy of
using a theoretical framework to guide the
telephone counseling by senior peers with no his-
interventions led to greater effects in coping and
tory of cancer for older women after breast
self-efficacy. A previous meta-analysis of nurse-led
cancer surgery; the patients in this study reported
supportive interventions for patients with cancer
that the PSI would have been more helpful if the
reported better outcomes when using approaches
peer counselor had been a breast cancer survivor
based on a theoretical framework (Suh & Lee,
(Crane-Okada et al., 2012). Cancer is a life-altering
2017). The use of an appropriate theoretical
event, and survivors have fears related to
framework can help guide the design of health
recurrence and face spiritual challenges related to
messages (Basil & Witte, 2012; O’Keefe, 2012),
having survived this illness. Cancer survivors may
including the use of appropriate emotional
have a better understanding of this response and
appeals (Turner, 2012); consideration of differences
be better able to empathize and provide
in health literacy (Chambers, Ferguson, Gardiner,
improvements in multiple dimensions of QOL,
Aitken, & Occhipinti, 2013); and customization of
including physical and psychosocial function- ing,
messages for individuals with different stages of
cancer symptoms, and overall well-being (Ferrell,
motivation (Noar & Van Stee, 2012). The tailoring of
Dow, Leigh, Ly, & Gulasekaram, 1995).
supportive care for participants using a theoretical
framework improves different types of health A peer’s counseling experience may significantly
outcomes (Albarracín et al., 2005; Cohen, affect perceived social support among patients with
Gottlieb, & Underwood, 2001; Hardeman et al., cancer, as suggested by the current authors’ sub-
2002). group analysis. The effects of PSIs on perceived
social support was not significant in the pooled anal-
Another reason for the small ESs may be that
ysis; however, patients with cancer who received PSIs
methodologic issues led to systematic bias and
from peers with counseling experience showed mod-
dimin- ished the ESs and their statistical
erate improvement in perceived social support (ES =
significance. The current authors’ subgroup
0.44). Given the potential vulnerability of patients
analyses showed that PSIs had larger effects on
with histories of cancer, recognizing the negative
emotional health and QOL in studies that were
effect of their cancer-related distress is important
RCTs and that had low risk of bias. A previous
(Giese-Davis et al., 2006; Söllner et al., 2001). A
meta-analysis of nurse-led supportive interventions
healthcare professional or experienced counselor
for patients with cancer reported better outcomes in
may more easily identify these signs of distress,
terms of emotional distress and QOL for studies
provide a safe and confi- dential place to talk, and
that were RCTs (Suh & Lee, 2017). The meth-
help to turn a personal health crisis into a chance for
odologic limitations of a study may bias the results
hope and healing.
toward no effect or increased effect (Higgins,
In addition, the effect of a PSI on emotional
Altman, & Sterne, 2011). More rigorous studies,
health, self-efficacy, and sexuality was stronger for
such as RCTs and those with a low risk of bias, are
studies with only face-to-face interactions, rather
more likely to yield reliable results.
than only telephone calls or mixed types of
Use of different types of peers for the PSIs may
interactions. In contrast, studies of patients with
influence specific outcomes. The effect of the PSI
psychiatric diseases suggested that interventions
on QOL became stronger when the peers were
using the Internet or telephone were as effective
cancer survivors (ES = 0.17) rather than spouses or
as face-to-face interventions in engaging the
intimate partners (not significant). However, the
participants (Andersson, Cuijpers,
effect of the
TABLE 4. Effect Sizes of Peer-Led Supportive Interventions on Combined Outcome and Individual
Outcomes
Relative
Outcome N V z Weight SMD 95% CI p
Combined effect of PSIs a
Ashbury et al., 1998 367 0.006 4.29 9.66 0.32 [0.17, 0.47] < 0.001
Bultz et al., 2000 34 0.025 1.16 5.49 0.18 [–0.13, 0.49] 0.247
Campbell et al., 2007 30 0.036 1.75 4.59 0.33 [–0.04, 0.7] 0.081
Chambers et al., 2015 189 0.023 –0.72 5.62 –0.11 [–0.41, 0.19] 0.47
Crane-Okada et al., 2012 136 0.014 2.15 6.83 0.25 [0.48, 2.25] 0.031
Giese-Davis et al., 2016 104 0.006 2.11 8.25 0.17 [0.01, 0.32] 0.035
Gotay et al., 2007 252 0.069 0.82 3.04 0.21 [–0.3, 0.73] 0.414
Lee et al., 2013 129 0.01 1.65 7.4 0.17 [–0.03, 0.37] 0.098
Napoles et al., 2014, 2015 151 0.009 3.36 7.67 0.32 [0.13, 0.5] 0.001
Pinto et al., 2015a 76 0.026 0.09 5.32 0.01 [–0.3, 0.33] 0.928
Porter et al., 2009 130 0.031 2.15 4.9 0.38 [0.03, 0.73] 0.032
Samarel et al., 1997 122 0.011 –0.25 7.3 –0.03 [–0.23, 0.18] 0.806
Weber et al., 2004 30 0.028 2.23 5.21 0.37 [0.05, 0.7] 0.026
Weber et al., 2007b 72 0.011 1.87 7.44 0.2 [–0.01, 0.41] 0.062
Wittenberg et al., 2010 73 0.051 3.94 3.71 0.89 [0.45, 1.34] < 0.001
Yun et al., 2017 206 0.004 0.99 8.86 0.06 [–0.06, 0.18] 0.321
RES 2,101 0.002 4.65 – 0.2 [0.12, 0.29] < 0.001
Bultz et al., 2000 34 0.121 0.91 6.41 0.32 [–0.36, 1] 0.36

Campbell et al., 2007 30 0.143 1.15 5.4 0.44 [–0.31, 1.18] 0.248
Pinto et al., 2015a 76 0.053 0.02 14.69 0.01 [–0.44, 0.45] 0.983
Samarel et al., 1997 122 0.033 0.1 23.57 0.02 [–0.34, 0.37] 0.919
Weber et al., 2007b 72 0.056 –1.09 13.78 –0.26 [–0.72, 0.21] 0.277
Yun et al., 2017 206 0.021 –0.33 36.15 –0.05 [–0.33, 0.24] 0.743
RES 540 0.008 –0.04 – –0.00 [–0.18, 0.17] 0.966
Bultz et al., 2000 34 0.122 –0.17 5.18 –0.06 [–0.74, 0.63] 0.866
Crane-Okada et al., 2012 136 0.042 2.77 13.69 0.57 [0.17, 0.97] 0.006
Giese-Davis et al., 2016 104 0.038 0.04 15.08 0.01 [–0.37, 0.39] 0.971
Lee et al., 2013 129 0.031 0.19 17.72 0.03 [–0.31, 0.38] 0.848
Napoles et al., 2014, 2015 151 0.027 1.29 20.12 0.21 [–0.11, 0.53] 0.196
Wittenberg et al., 2010 73 0.147 1.59 4.33 0.61 [–0.14, 1.36] 0.111
Yun et al., 2017 206 0.021 0.92 23.88 0.13 [–0.15, 0.42] 0.358
RES 833 0.007 2.25 – 0.18 [0.02, 0.34] 0.025
Bultz et al., 2000 34 0.12 0.29 5.38 0.1 [–0.58, 0.78] 0.773
Crane-Okada et al., 2012 136 0.041 –0.1 10.26 –0.02 [–0.42, 0.38] 0.919
Giese-Davis et al., 2016 104 0.037 0.37 10.78 0.07 [–0.31, 0.45] 0.715
Gotay et al., 2007 252 0.069 0.82 7.75 0.21 [–0.3, 0.73] 0.414
Lee et al., 2013 129 0.031 0.44 11.56 0.08 [–0.27, 0.42] 0.656
Napoles et al., 2014, 2015 151 0.027 2.04 12.23 0.33 [0.01, 0.66] 0.042
Samarel et al., 1997 122 0.033 –1.02 11.29 –0.19 [–0.54, 0.17] 0.306
12 ONCOLOGY NURSING FORUM MARCH 2018, VOL. 45 NO. 2 ONF.ONS.ORG

Outcomes (Continued)
Relative
Emotional health e
(continued)
Weber et al., 2004 30 0.145 2.19 4.68 0.83 [0.09, 1.58] 0.029
Weber et al., 2007b 72 0.059 2.99 8.48 0.73 [0.25, 1.21] 0.003
Wittenberg et al., 2010 73 0.158 2.8 4.38 1.11 [0.33, 1.89] 0.005
Yun et al., 2017 206 0.021 1.06 13.23 0.15 [–0.13, 0.44] 0.291
RES 1,309 0.009 2.39 – 0.23 [0.04, 0.41] 0.017
Ashbury et al., 1998 367 0.011 0.7 30.03 0.07 [–0.13, 0.28] 0.485
Campbell et al., 2007 30 0.141 0.36 2.56 0.13 [–0.6, 0.87] 0.721
Giese-Davis et al., 2016 104 0.037 1.37 9.52 0.27 [–0.11, 0.64] 0.169
Napoles et al., 2014, 2015 151 0.027 2.5 12.92 0.41 [0.09, 0.73] 0.013
Pinto et al., 2015a 76 0.053 0.11 6.74 0.02 [–0.43, 0.48] 0.915
Samarel et al., 1997 122 0.033 0.5 10.68 0.09 [–0.27, 0.45] 0.62
Weber et al., 2004 30 0.134 0.58 2.7 0.21 [–0.5, 0.93] 0.561
Weber et al., 2007b 72 0.056 –0.35 6.38 –0.08 [–0.55, 0.38] 0.727
Wittenberg et al., 2010 73 0.156 2.46 2.32 0.97 [0.2, 1.74] 0.014
Yun et al., 2017 206 0.021 0.62 16.14 0.09 [–0.2, 0.38] 0.535
RES 1,437 0.004 2.53 – 0.15 [0.03, 0.27] 0.012
Campbell et al., 2007 30 0.141 0.72 10.62 0.27 [–0.46, 1] 0.471

Giese-Davis et al., 2016 104 0.037 0.63 28.02 0.12 [–0.26, 0.5] 0.531
Lee et al., 2013 129 0.032 2.24 30.47 0.4 [0.05, 0.75] 0.025
Weber et al., 2004 30 0.147 2.39 10.2 0.92 [0.17, 1.67] 0.017
Weber et al., 2007b 72 0.059 2.94 20.69 0.71 [0.24, 1.19] 0.003
RES 365 0.018 3.19 – 0.43 [0.16, 0.69] 0.001
Bultz et al., 2000 34 0.135 2.8 9.34 1.03 [0.31, 1.75] 0.005
Campbell et al., 2007 30 0.143 1.27 8.98 0.48 [–0.26, 1.22] 0.205
Chambers et al., 2015 189 0.032 –0.74 19.24 –0.13 [–0.48, 0.22] 0.458
Giese-Davis et al., 2016 104 0.038 2.32 18.2 0.45 [0.07, 0.83] 0.02
Porter et al., 2009 130 0.031 2.15 19.4 0.38 [0.03, 0.73] 0.032
Weber et al., 2004 30 0.134 0.26 9.36 0.09 [–0.62, 0.81] 0.798
Weber et al., 2007b 72 0.056 –0.21 15.48 –0.05 [–0.51, 0.41] 0.836
RES 589 0.019 1.98 – 0.27 [0.00, 0.54] 0.048
Ashbury et al., 1998 367 0.011 5.41 22.31 0.58 [0.37, 0.79] < 0.001
Bultz et al., 2000 34 0.122 –1.13 11.08 –0.4 [–1.08, 0.29] 0.257
Crane-Okada et al., 2012 136 0.041 1.08 17.53 0.22 [–0.18, 0.62] 0.282
Giese-Davis et al., 2016 104 0.037 0.47 18.11 0.09 [–0.29, 0.47] 0.639
Weber et al., 2004 30 0.134 –0.31 10.53 –0.11 [–0.83, 0.6] 0.754
Yun et al., 2017 206 0.021 –0.46 20.44 –0.07 [–0.35, 0.22] 0.644
RES 877 0.024 0.73 – 0.11 [–0.19, 0.42] 0.467
Outcomes (Continued)
Relative
Health behavior j
Chambers et al., 2015 189 0.024 0.64 78.31 0.1 [–0.2, 0.4] 0.522
Yun et al., 2017 206 0.086 –0.17 21.69 –0.05 [–0.62, 0.53] 0.866
RES 395 0.019 0.49 – 0.07 [–0.2, 0.33] 0.626
Carlbring, Riper, & Hedman, 2014; Steele,

The current authors’ meta-regression
Mummery, & Dwyer, 2007; Wagner, Horn, &
analysis showed that the ES was not affected by the
Maercker, 2014). The effectiveness of a specific
number of sessions (p = 0.55), intervention period (p
type of intervention depends on the medical
= 0.951), duration of the session (p = 0.273), or
condition of the patients. To increase the impact of
sample size (p = 0.86). This is consistent with a
an intervention, determining the delivery mode and
previous review that examined the effect of
other characteristics that are best suited to different
psychosocial interventions on patients with cancer
target groups is important.
(Okuyama, Jones, Ricklefs, & Tran, 2015; Suh &
Despite the current authors’ subgroup
Lee, 2017). The number or duration of PSIs may
analysis, this study found that the PSIs did not
not adequately represent the intensity or “dose”
reduce cancer symptoms or alter health-related
of the intervention, the opportunity for
behaviors. Nurse- led supportive interventions (Suh
establishing a good relationship, the quality of
& Lee, 2017) had a moderate effect on improving
the interaction, or a trust-based relationship where
cancer symptoms (ES = 0.33) and a large effect on
outcome effects may be more apparent.
increasing healthy behaviors (self-care) (ES =
Consequently, different methods may be needed
0.64). This indicates that the effects of nurses
to measure the quality of PSIs.
and peers in providing supportive interventions
for patients with cancer are clearly dis- tinguishable.
Strengths and Limitations
In particular, nurses improve symptom management
and health promotion, whereas peers improve The strengths of the current study include the use of
self-efficacy (ES = 0.43). Empathetic sharing of a comprehensive search for publications that used a
experiences with patients who have cancer is gen- homogeneous peer-led supportive model (one-on-
erally beyond the scope of healthcare professionals. one interaction) for patients with cancer, assessment
The success of peers may be explained by Bandura’s of study eligibility and data abstraction by indepen-
(1997) self-efficacy theory, which uses concepts like dent researchers, appraisal of the risk of bias, and
mastery and vicarious experience. The PSIs provided use of moderator analyses. The results presented in
the opportunity to see others successfully this article broaden understanding of the many
manage problems related to cancer diagnosis and variables that should be considered when designing
treatment. These findings support the use of PSIs supportive interventions for patients with cancer
as a supplemental component of healthcare based on their psychosocial needs. This meta-
professional–led cancer care. analysis of the effects of peer-led supportive
interventions on patients with
cancer is the first analysis of these trials in 20 years.
However, it has several limitations. The trials
included were mostly of people with breast or KNOWLEDGE TRANSLATION
prostate cancer, which are cancers with strong ɐ Patients with cancer who have less social support are more
gender specificity, so the psychosocial needs of likely to experience distress.
these groups skewed the study statistics; in fact, this ɐ Supportive interventions delivered by peers may provide
simply reflects the reality that PSIs are more improvements in self-efficacy, sexuality, emotional health,
commonly evaluated for patients with breast or coping, and quality of life. However, the overall effects of peer-
prostate cancer than with other cancer types.
led supportive interventions (PSIs) were small.
Because patients with breast or prostate cancer
often have problems with sexuality, which most ɐ For a more effective care model, the PSI should be
people consider to be a private issue, researchers underpinned by theory, adopt high-quality methodology,
may employ appropriate selection of peers, and use peers with
counseling experience.
believe that a spouse or intimate partner would be
more effective in delivering these interventions. In
addition, patients with breast or prostate cancer had
longer survival times than those with other cancer
types, so these patients may be more interested in including high risk of bias, small sample sizes, and
learning life skills that improve QOL after cancer lack of long-term follow-ups, reduced the validity
diagnosis. They also may be in the midst of of the findings. The presence of so few trials with a
teachable moments and, therefore, be more likely to low risk of bias examining PSIs means that the
actively participate in the interventions. current body of knowledge about this topic is
Another limitation is that the mean age of the limited and that additional research is needed, as are
study participants ranged from 45–63 years. improvements in the methodology of these future
Considering that cancer can occur at any age, that trials. In particular, future trials should clearly
a need exists to address a broad range of patients, articulate the research methodology so that readers
and that more than half of all cancers occur in can better judge the risk of bias and more
adults who are aged 65 years or older (White et al., accurately interpret the findings. Well-designed
2014), this limits the generalizability of the results. RCTs, with adequate statistical power and
Examination of the effect of a PSI in older adult appropriate outcome measures, must be conducted
patients with cancer is challenging (Gollhofer et al., to confirm the current authors’ finding that PSIs
2015). In addition, for trials of supportive provide a benefit for patients with cancer.
interventions involving peers, having adult patients
with cancer participate volun- tarily may be difficult Implications for Nursing
because of a reduced ability to recognize their A major responsibility of oncology nurses is to
motivations, such as wanting to help others (Jenkins refer patients who are more vulnerable to distress
& Fallowfield, 2000) or wanting personal benefits and have a greater need for ongoing formal con-
(Catt, Langridge, Fallowfield, Talbot, & Jenkins, tact and support to valuable resources. The current
2011). Despite the difficulties in studying older adult review suggests that the PSI appears to be a valu-
patients, further emphasis on social support for able resource for patients with cancer. However,
this population of patients with cancer may improve PSIs had only small effects on sexuality, emotional
their physical and psychosocial function- ing health, coping, and QOL and no significant effect
(Coll-Planas et al., 2017; Smith, Banting, Eime, on cancer symptoms and health-related behaviors.
O’Sullivan, & van Uffelen, 2017). Because older adult The current authors believe these shortcomings can
patients with cancer are better at self-managing their be overcome by using a tiered evaluation that has a
health than older adult patients with other chronic theoretical underpinning, a high-quality methodol-
illnesses (Lee, 2016), peer-led supportive ogy, and an intervention that considers the intensity
interventions based on the cancer care and timing of the PSI according to patients’ needs
continuum, such as the Chronic Care Model and characteristics, as well as by carefully selecting
(McCorkle et al., 2011), may be effective for older peers regarding their experience with interventions
adult patients with cancer. Additional studies are and according to patients’ specific needs or
needed to evaluate the effects of the peer-led care desired outcomes. Nurse-led supportive
model on older adult patients with cancer in interventions and PSIs had different effects on
nursing practice. different outcomes (Suh & Lee, 2017). Therefore,
The potential bias of the included trials must the combined use of two care models in caring for
also be noted. The methodologic problems patients with cancer
encountered,
TABLE 5. Subgroup Analysis of the Effect Sizes of Study PSIs According to Outcome Measure
Outcome n SMD 95% CI z p I2 (%) Q p

Coping
Application of theory
Yes 4 0.21 [0.01, 0.41] 2.09 0.037 31 4.3 0.228
No 3 0.1 [–0.23, 0.43] 0.61 0.544 10 2.2 0.331
Emotional health
Control condition
Attentional control 3 0.24 [–0.28, 0.76] 0.91 0.361 78 9.1 0.011
Usual care or no intervention 8 0.24 [0.05, 0.43] 2.5 0.012 31 10.2 0.177
High 9 0.22 [–0.01, 0.45] 1.92 0.055 58 19.2 0.014

Low 2 0.3 [0.03, 0.57] 2.16 0.031 – 0.15 0.701
Face-to-face 4 0.47 [0.18, 0.75] 3.23 0.001 22 3.84 0.279

Combination 3 0.23 [–0.34, 0.79] 0.78 0.435 77 8.85 0.012
Telephone 4 0.1 [–0.08, 0.29] 1.14 0.255 – 0.7 0.874
Quality of life
Design
Non-RCT 2 0.44 [–0.42, 1.31] 1 0.318 79 4.8 0.028
RCT 8 0.16 [0.02, 0.3] 2.22 0.026 – 4.4 0.731
Attentional control 4 0.16 [–0.1, 0.43] 1.21 0.227 38 4.9 0.183

Usual care or no intervention 6 0.16 [0.02, 0.3] 2.19 0.028 – 4.4 0.496
Cancer survivor 8 0.17 [0.02, 0.32] 2.24 0.025 34 9.2 0.242

Spouse or intimate partner 2 0.1 [–0.22, 0.42] 0.6 0.547 – 0.01 0.915
Self-efficacy
Application of theory
Yes 4 0.53 [0.28, 0.77] 4.16 < 0.001 – 2.6 0.452
No 1 0.12 [–0.26, 0.5] 0.63 0.531 – – 1
Face-to-face 3 0.66 [0.3, 1.01] 3.65 < 0.001 – 1.59 0.453

Combination or telephone 2 0.29 [–0.00, 0.54] 1.93 0.053 12 1.13 0.287
Sexuality
Type of peer
Cancer survivor 4 0.09 [–0.21, 0.39] 0.61 0.544 44 5.3 0.149
Spouse or intimate partner 3 0.53 [0.18, 0.89] 2.94 0.003 21 2.5 0.283
Face-to-face 5 0.34 [0.01, 0.67] 2.04 0.042 41 6.8 0.145

Combination or telephone 2 0.15 [–0.42, 0.73] 0.53 0.598 79 4.9 0.027
TABLE 5. Subgroup Analysis of the Effect Sizes of Study PSIs According to Outcome Measure (Continued)
Outcome n SMD 95% CI z p I2 (%) Q p

Social support
Counseling experience of peer
Yes 2 0.44 [0.1, 0.78] 2.52 0.012 59 2.5 0.118

No 4 –0.05 [–0.26, 0.15] –0.51 0.611 – 1.6 0.668
CI—confidence interval; PSI—peer-led supportive intervention; RCT—randomized, controlled trial; SMD—standardized mean difference
Note. Bolded values indicate significant random effects subtotal.
may benefit the healthcare team and patients who

Both authors contributed to the conceptualization and design,
require multidimensional care. PSI programs in
clinical settings require an infrastructure that completed the data collection, and contributed to the manuscript
ensures oversight of peers, which includes staff preparation. Lee provided the statistical support and the analysis.
time for recruiting, supervising, and maintaining a
pool of peers; patient referrals and matching;
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ADVANCED PRINT EXCLUSIVE

With Cancer: A Meta-Analysis

PROBLEM IDENTIFICATION: To evaluate the effects

ONF.ONS.ORG MARCH 2018, VOL. 45 NO. 2 ONCOLOGY NURSING FORUM 1

Campbell et al., 2007; Porter et al., 2009).

with cancer, either via face-to-face or telephone

Study and Location Cancer Type Control Arm PSI Peers

rol workbook. simi- lar

Continued on the next page

Study and Location Cancer Type Control Arm PSI Peers

Study Characteristics of Peer-Led Supportive Intervention Time of Measurement

Continued on the next page

Study Characteristics of Peer-Led Supportive Intervention Time of Measurement

support indicated that the PSI group had no signifi-

healthy behaviors, and promoting positive

Ashbury et al., 1998 No No No No High

Campbell et al., 2007 Yes No Yes No High

Crane-Okada et al., 2012 Yes No Yes Yes High

Gotay et al., 2007 Yes Yes Yes Yes Low

Napoles et al., 2014, 2015 Yes Yes Yes Yes Low

Porter et al., 2009 Yes Uncertain Yes Yes High

Schover et al., 2006 Yes Uncertain Yes Yes High

Weber et al., 2004 Yes Uncertain Uncertain Uncertain High

Wittenberg et al., 2010 No No No No High

Yun et al., 2017 Yes No Yes Yes High

ONF.ONS.ORG MARCH 2018, VOL. 45 NO. 2 ONCOLOGY NURSING FORUM 11

The current authors further analyzed the

Bultz et al., 2000 34 0.121 0.91 6.41 0.32 [–0.36, 1] 0.36

12 ONCOLOGY NURSING FORUM MARCH 2018, VOL. 45 NO. 2 ONF.ONS.ORG

Campbell et al., 2007 30 0.141 0.72 10.62 0.27 [–0.46, 1] 0.471

Carlbring, Riper, & Hedman, 2014; Steele,

Outcome n SMD 95% CI z p I2 (%) Q p

High 9 0.22 [–0.01, 0.45] 1.92 0.055 58 19.2 0.014

Face-to-face 4 0.47 [0.18, 0.75] 3.23 0.001 22 3.84 0.279

Attentional control 4 0.16 [–0.1, 0.43] 1.21 0.227 38 4.9 0.183

Cancer survivor 8 0.17 [0.02, 0.32] 2.24 0.025 34 9.2 0.242

Face-to-face 3 0.66 [0.3, 1.01] 3.65 < 0.001 – 1.59 0.453

Face-to-face 5 0.34 [0.01, 0.67] 2.04 0.042 41 6.8 0.145

Outcome n SMD 95% CI z p I2 (%) Q p

Yes 2 0.44 [0.1, 0.78] 2.52 0.012 59 2.5 0.118

may benefit the healthcare team and patients who

20 ONCOLOGY NURSING FORUM MARCH 2018, VOL. 45 NO. 2 ONF.ONS.ORG

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