Cancer Caregiver Quality of Life: Meta-Analysis


 People living with cancer benefit greatly from informal caregivers. There has never been a previous meta-analysis on the quality of life of cancer caregivers or the efficacy of caregiver intervention programmes. The goal of this meta-analysis was to look at the quality of life of cancer caregivers and the impact of various initiatives aimed at improving it. From January 2006 to April 2021, a comprehensive literature search was conducted using PubMed, PubMed Central, Clinical Key, Google Scholar and Cochrane database. The effect of caregiver interventional programs on quality of life was evaluated using a mean difference between experimental and control groups. A random-effect model was used to measure the risk ratio (RR) for calculating the quality of life of cancer caregivers. The final report comprised eight trials with a total of 1142 participants. The caregiver intervention programme was found to improve the quality of life of cancer caregivers, but not statistically significantly (mean difference=0.10; p<0.00001). A caregiver interventional program had a positive effect on the quality of life of cancer caregivers, according to this meta-analysis. To prove that caregiver interventional programs are successful strategies for improving the quality of life of cancer caregivers, further randomised controlled trials are required.


Background
Advancement in technology and improvement in cancer diagnosis and care have resulted in a growing number of cancer survivors as evident by data given by International Agency for Research on Cancer (IARC) over 17.0 million new cancer cases and predictions of up to 27.5 million new cancer cases by 2040 globally. [1] By 2020, more than 19.3 million new cancer cases are expected to be diagnosed. [2] Approximately 43.5 million informal caregivers globally and among them one in every four caregivers spending 41 hours/week providing care to an adult or child. [3] Informal caregivers are often family members or friends who are responsible for caring for people who are suffering from a variety of ailments such as old age, dementia, or cancer. [4] These caregivers provide 70 to 80 percent of cancer treatment and are present with patient throughout the cancer care process from diagnosis till death. [5] Caring for someone with cancer can be highly taxing; 50% of cancer caregivers experience higher levels of stress and depression, [6] and 40% suggesting that they need assistance in handling their own emotional and physical stress. [7,8] Caregivers' burden is described as "the degree to which caregivers believe that caring for others has negatively impacted their emotional, social, nancial, physical, and spiritual well-being." [9] Increased anxiety, depression, loneliness, lack of social support, helplessness, loss of control, and fear of recurrence are examples of psychosocial symptoms faced by all caregivers including cancer caregivers also. [10] Lack of exercise, poor sleep, exhaustion, weight gain or loss, all of which contribute to decreased immune system function, coronary heart disease, and early mortality, are some of the more behavioural and somatic issues. [11] Lifting and moving heavy loads cause's musculoskeletal discomfort in caregivers in both older children and adult patients. [12] Thus all these affects overall quality of life (QOL) of caregivers. Furthermore, studies on caregivers of mentally or physically ill patients found that caregivers' quality of life (QOL) had a signi cant effect on the QOL of the people they were caring for. [13][14][15] Burden on cancer caregivers will last for years after the patient's initial cancer diagnosis, with evidence of long-term health and QOL consequences. [16,17] As a result, developing successful and realistic approaches to avoid and mitigate the psychological and physical stressors that minimise caregivers' QOL is critical.
[18] The aim of this meta-analysis is to identify and compare cancer patient's caregiver quality of life.

Methods
The analysis protocol was written by using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)-2020 [19] guideline to assess and compare quality of life of cancer caregivers. (Fig. 1)

Data sources and selection criteria
Online published research studies from PubMed, PubMed Central, Clinical Key, Google Scholar, and Cochrane from January 2010 and April 2021. The quest was limited to peer-reviewed publications, papers written in English and research concerning human subjects. The search strategy followed the PICO (population, intervention, control, and outcomes) format, P = Caregiver, I = Cancer, C = Patients, O = Quality of life. Medical Subject Headings (MeSH) terms used for population were "Caregiver", "Family caregiver", "Spouse", "Partner", with intervention were "Cancer", "Oncology", with control were "Patient", "Cancer patient" and with outcome were "Quality of life", "QOL" were used to search the literature.

Selection of study
Two reviewers (KKR and CVK) screened titles and abstracts separately to nd published studies. The research design included reported randomized controlled trials conducted in English from January 2010 to April 2021. Caregivers who are providing care to adult cancer patients were included. Exclusion criteria included studies involving children cancer patients and studies with qualitative methodology were excluded.

Outcome measures
Both independent authors (KKR and CVK) looked at the primary outcomes of the studies that were included, such as study characteristics and participant pro les. The main goal is to evaluate the quality of life of cancer patients' caregivers.

Data extraction
Data was extracted from the selected studies by two separate authors (KKR and CVK). Any differences in inclusion eligibility were resolved through discussion among the authors. Following the selection of each study, the data was tabulated in the form of author name, publication year, study design, study population, study characteristics, source of data collection, research tools and statistical methods used. Any necessary clari cations were obtained by emailing the correspondence author.

Risk Bias and Quality Assessment
The probability of bias was assessed separately by the writers KKR and CVK. Cochrane risk of bias assessment guidelines by Higgins et al were used. [20] Selection, performance, detection, attrition, reporting and other biases are included in the risk of bias graph and risk of bias overview for each selected RCT. (Figs.

& 3)
For each variable, all studies were categorised as low, high, or unclear risk. Any disagreements between the two independent authors were settled by consensus. The Chi-square test was used to evaluate heterogeneity using I 2 statistics of treatment effects among selected trials. Table 1   Continuous data on caregivers' quality of life outcomes was presented as a mean difference (MD) with a 95% con dence interval. Chi-square test was used to evaluate heterogeneity using I 2 statistics of treatment effects among selected trials. I 2 of 0% indicates no heterogeneity, 50% indicates minimal heterogeneity, and > 50% indicates substantial heterogeneity, according to the researchers. For the nal meta-analysis, the researchers used a xed-effect model with a signi cant p-value of 0.05 and an I 2 statistic of 50% (with nonoverlapping of CI in forest plot suggesting heterogeneity). All p-values were two-sided, with 0.05 indicating statistical signi cance. The funnel graph for the mean difference with standard error was plotted to analyse the caregiver quality of life to evaluate possible publication bias.

Study Selection and Characteristics
Initially, the PRISMA-2020 guidelines[30] were used to create the ow diagram that registered, screened, removed, and nally included in the search strategy. Using the PICO format (PubMed-24, PubMed Entral-10, Clinical Key-15, Google Scholar-18 and Cochrane-01) 68 studies were included, and 60 studies were omitted (Fig. 1). As a result of the screening, eight full-text RCTs quali ed, meeting all eligibility criteria of this metanalysis. Table 1 shows the characteristics of the eight trials that were included. A total of 1142 people took part in the eight trials in which caregivers were given training programmes to help them sustain and maintain their quality of life. For the primary outcome of caregiver quality of life, all eight trials had complete results.
To assess the impact of caregiver training programmes on maintaining their quality of life, funnel plots revealed no signi cant asymmetry from meta-analysis results (Fig. 4). The funnel plot of quality of life of cancer caregivers mean difference revealed no signs of publication selection bias. This metanalysis revealed that there is a need to plan, perform, and report research on caregiver quality of life so that can be put into effect, with an emphasis on e cacy. The metanalysis key nding was that experiments and evaluation tools for caregivers were not planned in a systematic ways to maximised the potential for interventions to be adopted effectively. From an existing framework, we can learned about the complexities of operationalizing implementation outcomes.

Limitations
According to this metanalysis, the documentation of cancer caregiver intervention research needs to be improved in order to promote their incorporation into practise. There seem to be two major concerns. To begin with, experiments were not planned in a way that maximised their chances of being implemented successfully. Second, in some cases, there is only a small amount of information available that is applicable to implementation.

Declarations Authors' contributions
The authors contributed equally to the conception and writing of the manuscript. All authors read and approved the nal manuscript.   Forest plot showing quality of life of caregivers