The aim of this scoping review was to provide a comprehensive synthesis of the current home-based, multimodal, self-management interventions (HMSIs) available for cancer patients. The primary areas of interest included the nature, extent and remit of existing HMSIs, potential obstacles to their implementation and the clarification of key terms and concepts. HMSIs will also be discussed in the context of the current literature on cardio-oncology.
The scoping review included 41 studies, representing 28 HMSIs. There was significant variation amongst HMSIs in terms of delivery mode, duration, location and target. Most HMSIs were ‘web-based’, which referred to the use of an online, independent platform that patients were able to access for a specific amount of time. The literature differentiated between these ‘web-based’ platforms and interventions that employed video conferencing technology: while the latter are also ‘web-based’, due to the live and interactive nature of delivery, the term ‘telehealth conferencing’ was generally applied to differentiate between both mediums. While all ‘web-based’ interventions can be accessed via mobile devices with internet connections, ‘mHealth’ or ‘mobile-based’, interventions designed specifically for a mobile devices were rarer, as were paper-based interventions. Although a growing body of evidence demonstrates the efficacy of digital interventions, the existing literature tends to bind both web- and mobile-based interventions together (e.g., in Kählke et al. [59]). As noted by Lorca-Cabrera et al. [60] future research may benefit from investigating the effectiveness of mobile-based interventions to ascertain which mediums are most accessible and successful for the delivery of home-based interventions, particularly for cancer patients.
There was a similar disparity observed between the duration of interventions. All of the interventions, with the exception of one; The Patient Information Leaflet [20] were within the range of one to six months in length. The Patient Information Leaflet, a one to two-week long intervention, was also the only intervention to focus exclusively on cancer ‘prehabilitation’ – a term defined as “a process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment” [61, p. 715]. Given that cancer prehabilitation has been identified as leading to better functional outcomes for cancer patients [62] this finding indicates that perhaps more interventions should focus on providing support earlier in the cancer care pathway and incorporating the prehabilitation period into their timeframe.
One notable finding was that of the 28 interventions included, only two were located within the UK; considerably fewer than the 12 in the US and half the number based in Korea and the Netherlands respectively. The two UK-based interventions identified were ‘RESTORE’ [29] and ‘SafeFit’ [53]. RESTORE was developed by the University of Southampton, in collaboration with Macmillan Cancer Support. An online, multimodal intervention that targets cancer-related fatigue, it is available for free for at https://macmillanrestore.org.uk/. ‘SafeFit’ is a remote trial, designed in response to the COVID-19 pandemic as a ‘virtual clinic’, enabling cancer patients to maintain contact with a cancer exercise specialist, to support their physical and psychological wellbeing. As of August 2023, the SafeFit website states “due to overwhelming demand SafeFit is currently at capacity, and we are unfortunately not able to take any more referrals at this time” (accessed at: https://safefit.nhs.uk/, 22nd August 2023). The scoping review did not identify any interventions targeting all six modalities and generalisable to all cancer types based in the UK.
Only four of 28 interventions included were non-cancer specific and generalisable to any cancer type; ‘Cancer Aftercare Guide’ [25]‘Cancer Thriving and Surviving’ [37] ‘SafeFit’ [53] and ‘Surviving and Thriving with Cancer’ [55]. None of these interventions included all six modalities identified by the thematic analysis (Physical Activity, Nutrition, Psychological Support, Patient Education, Lifestyle and Caregiver Support). In fact, the six modalities were only encompassed by one intervention: ‘Pack Health’ [22], an 8-week telehealth programme targeting cancer-related fatigue, which due to low engagement level, did not meet feasibility criteria. While all interventions included a psychological component (as necessitated by the inclusion criteria), the majority included at least three other components but these varied significantly between Physical Activity, Lifestyle, Nutrition and Patient Education. Only two interventions included a Caregiver Support component. A previous systematic review found that although the research on multidimensional cancer interventions is scarce, evidence has shown “statistically significant benefits for multidimensional interventions over usual care, most notably for the outcomes fatigue and physical functioning” [63]. However, it is clear from this scoping review that the term ‘multidimensional’ is ambiguous. If the term is to be defined using the ‘multidimensional’ interventions of cardiac rehabilitation, all six components identified should be incorporated, including a Caregiver Support section (e.g., the ‘Friends and Family Resource’ of the REACH-HF Heart Failure Manual programme [64, 65]).
Breast, prostate and haematological cancers were the most common types of cancer targeted by the interventions included in this scoping review. This finding can likely be traced back to an analysis of the distribution of cancer research spending from 2012, which showed that breast cancer, prostate cancer and leukaemia were funded at levels that appeared higher than their relative burden, while other cancers (e.g., bladder, oesophageal, liver and uterine cancers) were underfunded [66]. Fatigue has been reported as the most common symptom experienced by cancer patients, which, in conjunction with its persistent, distressing and debilitating nature [67] likely explains its prevalence as a subject of interventions. This finding would also indicate that even those interventions not solely focused on cancer-related fatigue, would benefit by incorporating it as a target component. Only four interventions were generalisable to all cancer patients. An interesting observation is that despite the wide distribution of cancer types and related symptoms targeted by the interventions, each consisted of an assortment of same six aforementioned modalities, indicating that regardless of cancer type, the same information (in terms of psychological support, physical activity, lifestyle, etc.) is relevant. In order to address the skewed distribution of cancer interventions, perhaps the future of multidimensional cancer survivorship care lies in the development of comprehensive, generalisable interventions that can be tailored, where necessary, to meet specific patient needs.
Surprisingly, no intervention included in the present review appeared to be oriented to the literature on cardiotoxicity and cardio-oncology guidelines. One intervention ‘INSPIRE’ [33] a programme for cancer survivors of hematopoietic cell transplantation, mentioned cardiovascular health as being a topic within its ‘Boosting Health’ module, but failed to reference cardiotoxicity or cardio-oncology guidelines. Similarly, from the information available, the remaining interventions did not appear to target the key cardio-oncology recommendations of preventing, detecting, monitoring and treating cardiac risk factors, with regard to the implications of cardiotoxicity in particular. Literature has long been highlighting the need for comprehensive and integrative survivorship care for cancer patients with cardiovascular comorbidities [68–70]. As noted by Sparano & Sahni [71] in relation to the recent ESC Guidelines [8] “there is no shortage of similar guidelines dating back to as early as 2014”. The findings of the present scoping review would suggest that, disappointingly, despite the significant volume of literature, the knowledge we have about supporting cancer survivors has yet to be successfully translated from theory to practice.
The PRISMA-ScR Guidelines [19] were implemented in order ensure the present study was conducted as accurately and effectively as possible. Nonetheless, this scoping review has some limitations. In order to make the literature search more feasible, a relatively specific search term was developed and, given the sizeable number of results, the bibliographies of included studies were not searched for further studies. This was justified by the research team as being in concordance with the Levac et al., framework for scoping reviews which emphasises balancing “feasibility with breadth and comprehensiveness” [72, p1]. Similarly, a critical appraisal of the included sources of evidence was also not conducted, as this was not deemed relevant to the objectives of this scoping review.